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rt <br /> Burnett County (� Office of Zoning Administrator d -V0 0 <br /> APPLICATION FOR - LAND USE - PERMITS 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •Z m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m y.J <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> lions of lh"e of Isconsin. O <br /> O <br /> ,�cti a <br /> OWNE I se Print) / Contractor or Surveyor or Agent o - <br /> Address Address <br /> City,State,Zip Code r ^3�� City,State,Zip Code _ <br /> Telephone //� Telephon'ey <br /> Permit(s)Applied for: lJ`�1 - `7�l '77 l� �l r�'�J 4.on ?'eiii/ <br /> New Building Filling/Grading 1AVe vj �c�Q <br /> Addition Moving o <br /> Sanitary Camping Unit �_ o <br /> Privy Sub isio = <br /> � " r <br /> o `~ <br /> Structure Use: <br /> a y homelcabin, garage, addition,etc.) 0 0 <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). p <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. n <br /> 6. description on a side o is form) as an ax statement. ° r <br /> PLOT PLAN B w <br /> e <br /> i <br /> i1 <br /> — — 0 <br /> Z <br /> h) ° <br /> tA <br /> Z <br /> 411y LWS✓'l'^ <br /> "t ' y 0 c<m w° D .m <br /> m <br /> 2 2 m <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my 0 <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 n <br /> PP f 9 Y ) 9 <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liabi ' ich may be a result of he County of Burnett relying on this information I am providing 'r n <br /> in this application. I agr o per it county o c with admi istering county ordinances or other authorized <br /> person to have acce he alfove d5piii pr i ny re Is time for the purpose of inspec 'on. <br /> 69 <br /> SIGN HERE <br /> ;i�furef owner r building contractor) (date) <br /> ZONING ADMINISTRATOR o o <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0000�m <br /> 00000 <br />