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I <br /> Burnett County Office of Zoning Administrator £ o <br /> APPLICATION FOR - LAND USE — PERMITS 3 ' <br /> s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- n �- <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 Wisconsin. m <br /> N � <br /> C <br /> OWNER,(Dlease Print) Co tractor or Su or or Agent O <br /> L�eYOmE C' �.^— 'mom <br /> m <br /> Address Address m r <br /> City,Stat Zip Code /� 1 City,State,Zip Code <br /> , `'/re,..i W f S S'/fi79 Y <br /> Telephone 7i5- 3yq-S570 g Telephone G <br /> Permit(s)Applied for: m <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> Structure Use: <br /> (family home/cabin,garage,addition,etc.) Z <br /> p I <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 plansmystPe signed and dated by <br /> the owner. 2 ! / `, 3 O / !^� !� �,q UU <br /> 3 <br /> v <br /> y <br /> li g <br /> 1 o <br /> chg <br /> o <br /> 01 <br /> 71 <br /> Z H <br /> ' J i '= <br /> i <br /> i ' I' "�'lp�S r on Ca 0.0 a E.N°fie' IVU �� m Q� =aoanx <br /> 1 I a <.i icy _._.3 <br /> �C7 �e � �L� N QNO �m <br /> Z O : `2 1 <br /> O o <br /> i 0 O <br /> O i : 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 0 —y <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) iTl 1 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- 0 [p' <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the ;Co: <br /> i <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offi- a' <br /> cials charged with administering county ordi ces or other authorized person to have access to the above described pre- <br /> mises at any r nable time for the p rp e f inspection. <br /> m ' <br /> -2 <br /> SIGN HERE 8� '• v' ` d' <br /> ( ' nat r of owner o g contractor) (difite o� <br /> ZONING /A MINISTRATOR G IJ N O IV T <br /> TOWNSHIP PERMIT MAY BE REQUIRED �000 io <br />