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Qat C 0)47-) f <br /> Burnett County Office of Zoning Administrator d o a <br /> APPLICATION FOR — LAND USE — PERMITS 2. 3. <br /> d o <br /> TO THE ZbNING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 <br /> tions of the State of Wisconsin. <br /> _ o <br /> Morn 26 Star 'V = o <br /> a [r E <br /> OWNER( ease Prveyor rin ) a Contractor or Sur Agent <br /> �sr. 2r � W/�3�t r4tl« r✓yi - ,�1�� r1�.z ��830 � � � 3 <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code `1 \� <br /> Telephone Telephone V� K <br /> Permit(s)Applied for: ` <br /> New Building Filling/Grading , <br /> Addition Moving o `` <br /> SanitaryCamping Unit o G) <br /> 0 <br /> Privy Subdivision 0 <br /> IVPA�1 c�r'1� C , t <br /> Structure Use: <br /> (family homelcabin, garage, ddition,,d tc.) o vo <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. 1, 0 <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 /> J <br /> CO ��t3 a legal description on a side of this form o <br /> as on tax statement. 3 <br /> o � <br /> o,. <br /> S.J I V Cl <br /> C7 <br /> N o <br /> N <br /> O _ <br /> m <br /> �1 <br /> Z <br /> 0 <br /> Z <br /> d <br /> a w 'n n m <br /> n a < o n <br /> O <br /> T. <br /> OZ <br /> 0 0 0 O O <br /> ^ C m <br /> O: O : <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 m <br /> PP (including Yaccompanying ) g n <br /> information contained in this application includin an schedule and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which maybe a result of the County of Burnett relying on this information I am providing y <br /> in this application. I a ree to permit county officials charged with administering county ordinances or other authorized c <br /> person to have acce to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> m <br /> SIGN HERE <br /> (sign of owner or i1019g ontractor) (date) <br /> ZONING ADMINISTRATOR -^� <br /> v T <br /> OWNSHIP PERMITS M BE REQUIRED N o o N m <br /> 00000$gfA <br />