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' <br /> Burnett County Office of Zoning Administrator ; 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 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions o he State of Wisco in. <br /> N � <br /> OWNER(PleasePrint) Contractor or Su eyor or Agent n F <br /> WC MtP L )._z SY9 sa d o0 <br /> Address Addres <br /> City,State,Zip Code City,State,Zip Code t 1 <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 /> r. <br /> N <br /> Structure Use: -- 5 zn - _`` k` 0 <br /> (family home/cabin, garage,addition,etc.) o d <br /> m <br /> i. 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. o <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 /> O <br /> 0 <br /> 3 <br /> a o <br /> Z <br /> O <br /> �4 •�� <br /> N <br /> rA <br /> 0 <br /> ' 3 <br /> � a <br /> v o 0 <br /> N � <br /> U i <br /> Z <br /> O <br /> Z <br /> m c 0 m0ncmm <br /> any <br /> a 0�3 <br /> O N 9 <br /> Tnt ` I c : m <br /> [ : o : E O <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of W <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are)responsible for the °C.^: m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) <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 Eo: <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 ordinances or other authorized person to have access to the above described pre- iN i <br /> re- <br /> mises at�le time for the-p�,po a of inspection. ' <br /> i <br /> to :rr: <br /> SIGN HERE <br /> (si ure,of owner orb ding c ntractor) (date) a ? o <br /> o <br /> ZONING ADMINISTRATOR I ` 8 m <br /> N N O V <br /> � m <br /> OWNSHIP PERMITS MAY BE EQUIRED <br />