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l 4 <br /> Burnett County Office of Zoning Administrator ( o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> d m s ; <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 57-a S <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 n r S ' <br /> tions of the State of Wisconsin. y o <br /> C C. <br /> n O <br /> OWNER P t Contractor or Surveyor or Agent 1 <br /> �s�PleasedI&,,A <br /> Add ss Address <br /> City,State,Zip Code City,State,Zip Code I <br /> C <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit 5to <br /> 0 4 <br /> Privy Subdivision 'm ,p <br /> 4 1 <br /> Structure Use: <br /> (family homelcabin,garage,addition,etc.) 0 0 <br /> 9 <br /> m <br /> Z <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. 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. �1 <br /> O 1131 <br /> 6PL �pv a egal description on the side of this form) as on tax statement. 3 I <br /> LAW a m <br /> Z c <br /> / O n <br /> f' G <br /> N <br /> r�' o <br /> I E. <br /> s <br /> Ll <br /> 1�K�6 <br /> C11 <br /> plot <br /> lj <br /> VS <br /> a I <br /> 0 <br /> T <br /> Z h <br /> 0 <br /> YI d <br /> 11 N_ rD>W <br /> m <br /> n<c _ ww � ncm <br /> man� <br /> USE <br /> Z O <br /> O > : <br /> m <br /> O N' o <br /> — o: c: C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all : m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that r, a ' O <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 0)ic <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE E <br /> (si at a of owner or g contractor) (date) E `: <br /> o: o <br /> o: b <br /> ZONING ADMINISTRALL <br /> TOR o: o <br /> w m <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N oomp'm <br /> �0 0 000fQ <br /> J <br />