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Burnett County Office of Zoning Administrator m o 0 <br /> PERMITS <br /> APPLICATION FOR — LAND USE — 3 <br /> z s r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M H <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 /> L sof the State of Wisc sin. <br /> OWNER Please Print `� n O <br /> ( ) Contractor or Surveyor or Agent E <br /> Address <br /> // Address <br /> 2(Xhf�2! e <br /> City,State,Zip Code / City,State,Zip Code (� " <br /> Gid <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building - <br /> Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit m ' <br /> n <br /> Privy Subdivision o <br /> Structure Use: <br /> h"i42bu_e �f k '�y ` 67 " o <br /> (family home/cabin, garage, addition,etc.) Z v <br /> a <br /> a <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). 4 <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. <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 rC <br /> the owner. <br /> o <br /> a p <br /> R c�j <br /> co <br /> 'v .. a <br /> a PPC5 <br /> N, <br /> /a, o 0 <br /> N J o <br /> iJ <br /> Z <br /> GCS// 1J� D <br /> i n <br /> a < ; mcm - -3 <br /> N 2 N O m <br /> QCT. C i c M <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 MI <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) ' '^ 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 ;CD <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- ' iNE <br /> mises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> ' <br /> .(si r <br /> of owner b 'Id' g contractor) date) <br /> ZONING ADMINISTRATOR N N O N <br /> NNfT tT00 <br /> TOWNSHIP PERMIT MAY BE REQUIRED 000000 <br />