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cin c a <br /> Burnett County Office of Zoning Administrator f o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> TO 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 /> tions <br /> ,' 2fof te � .7_h State of Wisconsi .. <br /> ScZ�w cy m <br /> w v <br /> c <br /> m <br /> OWNER(Please Printf) Contractor or Surveyor or Agent a F <br /> �ogl9 J%4r✓��Hd' (f N <br /> m <br /> AddressAddress <br /> 1"4 'a/,-A0 1 /&' <br /> City�Sta-t Code City,State,Zip Code „!-1 <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 /> N <br /> Structure Use: GQ rVe a <br /> (family home/cabin, garage,addition,etc.) Z <br /> o <br /> a <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 /> / a <br /> Z <br /> S'�enCe✓ / —C. <br /> / ria <br /> , q.q <br /> dM1 n <br /> N <br /> OO <br /> 1 <br /> \ 0 <br /> � O <br /> 0 <br /> {fu�l'v5 <br /> v <br /> —;� z <br /> 0 <br /> z <br /> / <br /> M <br /> 7o NVNr D Dozy <br /> o a< >> o a= <br /> / ,e rni zmo �(o <br /> m,z : 1 <br /> :A N: M m <br /> y' o` O <br /> o c C <br /> re)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o <br /> (our) knowledge and belief it is true, correct and complete. I (we)acknowledge that I (we)am(are) responsible for the [ m <br /> tail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) l <br /> ther declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- f ErE <br /> It Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the m <br /> linty of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- <br /> 4s charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> Aes at any reasonable time for the purpose of inspection. <br /> a: <br /> m i ice: i <br /> tIQ,I HERE <br /> ?— <br /> (sig ture of owneror ilding contractor) (date) <br /> ING ADMINISTRATOR <br /> IJNON� N <br /> (TN(TO N <br /> TOWNSHIP PERMITS MAY BE REQUIRED o000 0 <br />