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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR — LAND USE — PERMITS <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m m <br /> w <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- lk 3 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions the State of Wisc in. 0 y m <br /> OWNER . £ <br /> J�eu <br /> rveyordr Agent <br /> Address Address = , <br /> City,State,Zip Code City,State,Zip Code C r� <br /> Telephone Telephone <br /> Permit(s)Applied for: \ <br /> New Building X Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> 0 <br /> Structure Use: ,o 0 <br /> v <br /> (family home/cabin,garage,addition,etc.) o 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. <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 /> v o <br /> Z <br /> 0 <br /> N <br /> a <br /> I a <br /> c r <br /> o <br /> o <br /> m m <br /> 0 <br /> lc' <br /> :7 w <br /> 9 <br /> Z <br /> 0 <br /> Z <br /> I� <br /> DD ooh <br /> < oama—.m <br /> m arc --nm ';aM <br /> Z m.: m O 7 f0 <br /> O : W'Z 1 <br /> O � <br /> Co : O <br /> c <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) <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 E ai <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- E in E '• <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (sign re o owner or 'Idi c tractor) J (date o <br /> of <br /> ZONING ADMINISTRATOR d �' <br /> OWNSHIP PERMITS MA)41E REQUIRED �0�800 0 <br />