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BurrW' County Office of Zoning Administrator ; f o <br /> APPLICATION FOR — LAND USE — PERMITS 3' <br /> _ o <br /> rO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> Located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> 'o <br /> do f the State of is opsin. � m m <br /> 07N R,(Please Print) Contractor or Surveyor or Agent o u�� <br /> `� yT <br /> Add�r s Address g I <br /> c,T <br /> City,State,Zip Code City,State,Zip Code <br /> 1 <br /> Telephone Telephone �,Cl <br /> Permit(s)Applied for. '" 1 <br /> New Building Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit <br /> 3-1 <br /> Privy Subdivision <br /> n d w <br /> /O 0 <br /> (family home/cabin,garage, addition, etc.) o 0 <br /> 0 <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. o <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, <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 /> O <br /> 0 <br /> 3 r <br /> O O <br /> Z <br /> O <br /> 1 <br /> � N <br /> c <br /> fN n <br /> P <br /> N <br /> a <br /> ca <br /> U � <br /> C <br /> o _ o <br /> 71j y, <br /> 1 <br /> Z <br /> c <br /> P <br /> S <br /> ► `� <br /> oe <br /> S�CN" 7p rnvmr> <br /> m c -.mm0ncm <br /> o = - � C N O O 3 <br /> Z m: i W O ! 0 <br /> O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the = m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) EnE O <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the a <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi. ` ice'. <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- Em <br /> mises at any reasonable time for the purpose of inspection. <br /> �� � l/ :rr <br /> SIGN HERE /�V �O�/ <br /> o: o <br /> (sign re of owner or buildin contractor) (date) <br /> ZONING ADMINISTRATOR <br /> % oNm <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0 0 S8m <br /> J <br />