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Burnett County Office of Zoning Administrator Cr 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d o <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- m c Y� <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n 6 <br /> tions of the State of Wisconsin. o I p <br /> / <br /> f� Sr •r k S ril"r' �h A O <br /> FlE n f <br /> OW R(P se Print) Contractor or Surveyor or Agent <br /> Address t Address <br /> l.0 c Tr r W I . S-gr P/�3 <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone SO <br /> Permit(s)Applied for: I <br /> OQ <br /> New Building Filling/Grading <br /> Addition Moving o (/) <br /> Sanitary Camping Unit ct <br /> 0 0 <br /> Privy Subdivision <br /> Structure Use: t'TN I N <br /> (f mily home/cabin,garage,addition,etc.) o a <br /> a <br /> _ m <br /> Directions for plot plan drawing: <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). <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, Q <br /> river or stream, if applicable. V <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 N <br /> �COfpekY de legal description (on the side of this form) as on tax statement. 3 H <br /> V y <br /> Z a <br /> A $ <br /> O <br /> J <br /> Jj <br /> I c� <br /> (y N <br /> O <br /> J <br /> O <br /> b <br /> Ck <br /> » <br /> T <br /> 70 0O <br /> Z <br /> I I\ <br /> M c w tai acmes <br /> O o J nn-.m <br /> y <br /> O G d N O J ic <br /> Z o i 5D <br /> O J 0 <br /> J o, <br /> m <br /> n 0 <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o c C <br /> PP ( 9 Y ) Y ll `o: m <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that ' A <br /> PP ( 9 Y ) 9 t7 <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a i o ' <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> �p m <br /> SIGN HERE <br /> igre of ownep building contractor (date) <br /> o; o <br /> ZONING ADMINISTRATOR <br /> N N O J N M <br /> OWNSHIP PERMITS MAY BE REQUIRED $vv v v PO�m <br /> 0000000 <br /> 0000000 Vl <br />