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Burnett County Office of Zoning Administrator m s o <br /> APPLICATION FOR — LAND USE — PERMITS 3 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and -u m S <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 f the State Wis onsin. o <br /> �f y N <br /> FfrN c7 • /✓IQAIEnZ)F_ej one <br /> OWNER(Please Print) Contractor or Surveyor or Agent °- F <br /> /615 a�w A�� r(•uJ - m <br /> AdIress Address m <br /> NeLJ6KIbidiaAJ ti(.d 55)! aL 1 <br /> Ty,State Zip Code City,State,Zip Code ct <br /> ,(or2 � -7 <br /> Telephone Telephone lv <br /> Permit(s)Applied for: -- Y �q¢�—QeL1= <br /> New Building T Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> Structure Use: r'A-N( r 1Y ` stn G'rQ l A e.e.../IC,e.COo <br /> (family home/cabin, garage, addition,etc.) Z <br /> P ° <br /> v <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 /> 0 <br /> 0 <br /> 9 p <br /> Z <br /> I <br /> a <br /> a <br /> N <br /> N <br /> Wtt� vur�cw�� Ap( 'o� <br /> m ^ <br /> 0 <br /> w � <br /> w <br /> m <br /> m' <br /> Z <br /> 0 <br /> 2 <br /> 9 <br /> ]7 Nvcnr DDmy <br /> 0 Q<'? . ° Ra S.° n m <br /> - <br /> m n�c =am FL <br /> y m o m 3 <br /> o <br /> N: : m <br /> «€ ' 2 m <br /> i c 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 them <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) m <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- :o <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the i :c! <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- im[ <br /> cials charged with acI70nistering county ordinances or other authorized person to have access to the above described pre- '• fn <br /> mises at any reason ble time for the purpose of inspection. <br /> SIGN HERE /0 - :5, oo <br /> (sig t u of owner or i 'ng contractor) <br /> (date) �: : <br /> ZONING ADMINISTRATOR 'Z� T <br /> N N O N <br /> PPP°NO <br /> TOWNSHIP PERMI MAY BE REQUIRED 00000 (mA <br />