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Burnett County Office of Zoning Administrator c f o <br /> APPLICATION FOR — LAND USE — PERMITS2. <br /> 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � y <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'sc nsi <br /> OWNER acip <br /> (Please Print) _ Contrr or SuX ryeyor or AgenSJIo <br /> � C'. �� <br /> Address , Addr s <br /> City,State,Zip ode i City, State,Zip Code } n` <br /> Telephone Telephone rl <br /> Permits)Applied for: "\ <br /> New Building Filling/Grading <br /> Addition Moving o - <br /> Sanitary Camping Unit N <br /> Privy Subdivision 0 17 <br /> N <br /> Structure Use: 0 <br /> v <br /> (family home/cabin, garage, addition,etc.) z <br /> 0 0 <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 /> g <br /> f 1 l` ,c+'oV0 <br /> v <br /> w <br /> I o <br /> N\� <br /> o I <br /> 0 <br /> m�J A <br /> or 0 <br /> J <br /> `xJ i <br /> 21 <br /> Z <br /> Z <br /> 31 mvfnr D DOo9 <br /> 0 0 n c m <br /> m a nm f;ny <br /> a °c' om3 <br /> p w 0 M m <br /> Z of <br /> 0 <br /> m <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 the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) C <br /> further declare that I(we)recognize that this information I(we)am(are)providing will be relied upon by the County of Bur- `'I E <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 <br /> V: N <br /> (si ture of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR <br /> �m Nm <br /> o 0 0 0 0 0 o <br /> TOWNSHIP PERMITS MAY BE REQUIRED V1 <br />