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7� l <br /> Burnett County Office of Zoning Administrator d - o a <br /> APPLICATION FOR - LAND USE - PERMITS3 <br /> 0 r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �2 m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 c S <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n <br /> tions of the State of Wisconsin. o r" <br /> OWNER(Please Print) Contractor or urveyor or Agent n 3E <br /> ��t f �esy <br /> d <br /> AddrgSS (' Addres m <br /> -�o'd tfw c �V0'j e jl,f. S •c= ., � ..F ".,1.' t. `a>.,, V <br /> City,State,Zip Code City,State,Zip Code <br /> io :,-C c.- l i ��O(p 7`f r <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition �� Moving o <br /> Sanitary Camping Unit <br /> 0 <br /> Privy Subdivision 0 15. <br /> CA <br /> m r <br /> r ( o a O <br /> Structure Use: <br /> (family hometcabin,g rage,addition, etc.) o a° <br /> m <br /> Directions for plot plan drawing: <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). <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 /> n <br /> -- -­ttrts <br /> u T'In 9'9 M n L3X StateMenfo <br /> PLOT PLAN t__ - 3 <br /> c <br /> NSU%9'` <br /> m <br /> n <br /> G 0 <br /> = r <br /> 0 <br /> to � <br /> T <br /> � Z <br /> c <br /> rp <br /> Cn <br /> a <br /> Z <br /> I a <br /> «€ m <br /> c <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all W c m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that J <br /> PP ( 9 Y ) 9 p E m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oo <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized n <br /> person to have access'to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> SIGN HERE <br /> v si re of owner or uilding contractor) • (date) E [ o; o <br /> o o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PE ITS MAY BE REQUIRED Nm <br /> T TNN O T <br /> ooco oom <br /> 0000�ooW <br /> lV <br />