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Burnett County Office of Zoning Administrator ; -m £ o <br /> APPLICATION FOR — LAND USE — PERMITS z f0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m m OO <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 0. <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- it <br /> tions of the State of Wisconsin. V" <br /> w m <br /> m � <br /> c <br /> m <br /> OWNER,(�PIase��P�rit) Contractor or Surveyor or Agent a F <br /> E �. SAI/DEIQSon� R <br /> d DQ <br /> Address <br /> k6 <br /> � 61 <br /> 9X ��s^ Address `? t <br /> City,State,,,y�!Code - n City, State,Zip Code p�c� <br /> Vk 6-DE- 0 CUi 5'��3 J Q <br /> Telephone 31i-.?33- O FE c��a-usx-abs Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> Privy Subdivision o <br /> C/) <br /> Structure Use: teT o <br /> (family homelcabin, garage, addition, etc.) z o <br /> 9 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. 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 /> 0 <br /> Y o <br /> 0 0 <br /> Z <br /> S <br /> v N <br /> C <br /> � a <br /> o <br /> o <br /> 0 <br /> Uri <br /> O <br /> Z <br /> 7:5 <br /> I , , <br /> m c�m w n a c rn <br /> n v > > ca-.rfl <br /> ✓ N' m <br /> m <br /> °1 n : i O <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 m <br /> my(our)knowledge and belief it is true,correct and complete. I (we)acknowledge that I(we)am(are)responsible for the ^ y 0 <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) 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. 0r <br /> v: <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- 3� <br /> mises at any reason Ie time for the purpose!of inspe tion. <br /> SIGN HERE r 2� 9j: <br /> (sign tur r or buildin o ractor) (date) <br /> ZONING ADMINISTRATOR �G�.-C <br /> IVNOiJL LN <br /> (TNNN OOfT <br /> OWNSHIP PERMITS MAY BE REQUIRED 000000 <br />