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Burnett Giunty Office of Zoning Administrator w M 0 o <br /> APPLICATION FOR — LAND USE — PERMITS 3. ' <br /> z s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v r,, , <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n y-,/ <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- - <br /> tions of the State of W'sconsin. m m <br /> OWNER(Please Print) Contractor or Surveyor or Agent °- <br /> Address _ Address `= <br /> City,State,Zip Code y'-�� City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision <br /> l� y <br /> Structure Use: 5yN _q ° <br /> (fa ily home/cabin,garage,addition, etc.) Z o <br /> 0 9 <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(OF). N <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 /> n ` <br /> 0 <br /> p <br /> Z <br /> 0 <br /> ~ I� <br /> C N <br /> C <br /> O <br /> n <br /> w <br /> . O <br /> 0��� � <br /> p'Y-� <br /> _O N <br /> A <br /> m .O. <br /> O �^ O <br /> 0 o n <br /> Z <br /> 1 � <br /> nn-'m <br /> Zi ic m <br /> C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of S: ? m <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are) responsible for the E n M <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) i i i �; O <br /> `•irther declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- O <br /> ' Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- j i m <br /> ­ied with administering county ordinances or other authorized person to have access to the above described pre- . p <br /> reasonable time for the purpose of inspection. <br /> 41 <br /> (sig e of/owner or 'din c ntractor) (dat <br /> n 71 <br /> ooNm <br /> OWNSHIP PERMITS MAY BE REQUIRED <br /> 00 0000rn <br />