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r- <br /> Burnett County Office of Zoning Administrator ; 'Mo E o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> z <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v 00 j <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 CM L � <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tiofs of the/tate of Wi consin./ m m <br /> OWNER(Please Print) Contractor or Surveyor or Agent n F <br /> to /S E illa�vLe.+ I v o <br /> AddressAddress <br /> S f T/�¢w� YN w S` 'T/U k <br /> City,State,Zip Code City,State,Zip Code <br /> - 7 7y' c') 371 P <br /> Telephone Telephone <br /> Permit(s)Applied for: i %\ <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> w A <br /> Sr�n� r On I i A <br /> Structure Use: .o <br /> (family homelcabin, garage, addition, etc.) Z o <br /> P v <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. rlo <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 O <br /> the owner. <br /> O <br /> 0 <br /> a o <br /> Z <br /> 0 <br /> C , <br /> � a <br /> � w <br /> ly <br /> 0 <br /> rn <br /> m <br /> m <br /> 0 <br /> w = <br /> n <br /> i <br /> T <br /> ✓ �.� V ) � <br /> �ac, <br /> J Z <br /> p <br /> r <br /> n o- 00.—m <br /> m a am ';n� <br /> O0 <br /> Z : !DQ <br /> P = E S <br /> 11 N: <br /> O[ [ O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best <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) 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 <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- <br /> mises at any reasonable time for the purpose of inspection. ' <br /> m <br /> SIGN HERE S -y'� ? c o <br /> (sign re f owner Iding contractor) (date <br /> _ o: o <br /> ZONING ADMINISTRATOR ti N o N N T <br /> rn ut ut<n o o cn m <br /> TOWNSHIP PERMITS MAY BE REQUIRED o$ o 0 0 o fmA <br />