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Office of Zoning Administrator o <br /> APPLICATION FOR — LAND USE — PERMITS 3 —" <br /> . ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � y <br /> .on herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n <br /> .and Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> .�State of Wisconsin. O <br /> AIER(P ease Priryt �� Contractor or Surveyor'orrAAgent a �, <br /> �� K-f' <br /> Address Address Q� <br /> 450 &04%49 ST <br /> City,State,Zip Code / City,State,Zip Code t <br /> ��r� Bye � Coe) <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit � l <br /> Privy Subdivision 0 <br /> _ <br /> ( 1/GY/v O <br /> Structure Use: v <br /> (family home/cabin, garage, addition,etc.) Z o <br /> o � <br /> m <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o <br /> 2. Show the location of the well (W),septic tank(ST), and drainfield(DF). <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within 300 ft. �T <br /> 4. Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to lake, O o <br /> river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by <br /> the owner. <br /> n <br /> 0 <br /> v <br /> Z <br /> 0 <br /> W. <br /> yCn <br /> v1 '1 a <br /> 0 A <br /> N <br /> t <br /> O <br /> 7 (n <br /> yT <br /> Z <br /> m !nv(nr DDao-a <br /> CW <br /> N (A 0 7 m <br /> A <br /> m <br /> O <br /> re)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o`. m <br /> (our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are) responsible for the rn <br /> tail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <br /> —cher declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- ' <br /> ;o: <br /> t Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i . ;o: <br /> Enty of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- N <br /> harged with ad ' istering county ordinances or of uthorized person to have access to the above described pre- 0 <br /> any reaso I tim r the p ose of in a ion. (D <br /> sig t eof er buil ontractor) (date) <br /> 9ATOR ' N N O. ro 6S <br /> cnvt(ncn0ocnrmn <br /> /TOWNSHIP PERMITS MAY BE REQUIRED o 0 0 0 0 0 C-:1 fp <br />