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Burnett County Office of Zoning Administrator co _0 0 a <br /> APPLICATION FOR — LAND USE — PERMITS 1;2W - 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 00 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <br /> 3 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. wLV <br /> m <br /> o <br /> — _ y g <br /> OWNER(Please Print) Contra or or Surveyor or Agent rs <br /> � <br /> Add s Address �S �/ <br /> �� eG 136X ccS / l <br /> Cit , Sate,Zi Code <br /> It <br /> Cil,Sta�`gCode��„ T�r <br /> Telephone Q�J Telephone P 6-�a 87 .c� <br /> Permit(s)Applied for: / y <br /> New Building _ Filling/Grading T <br /> Addition Moving O r <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 <br /> o <br /> Structure Use: <br /> (family home/cabin, garage, addition,etc.) o o <br /> a <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 /> O <br /> 0 <br /> 3 <br /> a <br /> a <br /> vii off 111 a o <br /> s o a <br /> I <br /> CD <br /> Z <br /> 0 <br /> Z <br /> p <br /> on Ca rAr 00 aaDDWy <br /> a <' wcmo's'3 <br /> Z w ? 0 0 3 m <br /> 0 o f <br /> m::zi <br /> 0 ' M <br /> NoRr � <br /> N n p <br /> of : : <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of o <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) n: 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- F <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the :a i <br /> County of Burnett relying on this information I(we)am(are)providing in this application.I(we)agree to permit county offs- i i ?Q <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 /> SIGN HERE <br /> (si nature of owner o buildingcontractor) (date) <br /> g c <br /> ZONING ADMINISTRAT <br /> TOWNSHIP PERMITS MA BE REQUIRED o$$o0 0 <br />