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Bumett County Office of Zoning Administrator m o 0 0 <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 m 00 Q <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 0. r 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 Wiscon in. w o <br /> Mhs ,anA % e-nri ° <br /> OWNER(Please Print) I Contractor or Surveyor or Agent n E <br /> w ��^ <br /> A ss C ,pyo �� �✓'M� ` (/� . Address '3 <br /> City,State,Zip Cod /6Y3 2"f SgTLS� City,State,Zip Code q T. <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving O a \. <br /> Sanitary Camping Unit 1 <br /> Privy Subdivision o` fns <br /> Structure Use: + � 3. <br /> (family home/cab n, garage, addition,etc.) Z o <br /> o <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). 0 <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 /> a 0 <br /> Z <br /> L� � C�� w'1! 'K• � c <br /> 1 n <br /> N <br /> �\ O <br /> J J <br /> y f o ) <br /> N <br /> ( m 0 <br /> 1 t y� r01 <br /> u <br /> v 0 <br /> N (� <br /> W <br /> P <br /> IV1 <br /> FA 7-3 <br /> CX <br /> 1 y Q{ r�¢- p1vNr DDmy <br /> / t 1 • Z" 9: <br /> t . " Q CAtD. ( ! 7 Nof'� Ir ✓n� v n � cwo�3 <br /> Ao'LArP s usl�, rSLLWKKr[ a o: <br /> rA <br /> In <br /> C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of V E '• <br /> my(our)knowledge and belief it is true,correct and complete. I(we)acknowledge that I(we)am(are)responsible for the j ` A <br /> : 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- '• :Fi <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the [p <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. [ En <br /> mises at any reasonable time for the purpose of inspection. i. : <br /> Err! <br /> SIGN HERE <br /> (signat owner b ' i contractor) date) <br /> ZONING ADMINISTRATOR <br /> N NO V <br /> TOWNSHIP PERMITS MAY BE REQUIRED 0 0 o w <br />