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Burnett County - Office of Zoning Administrator W0 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> v o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 5 {� <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <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. m o <br /> , m <br /> GIC)( L/ U///1/ Q /J. JSK/ a QJ O <br /> OWNE (P e e Print) Contr or or Surveyor or Agent <br /> - rhQA)R OE E moo. , }�� /a� <br /> Address Address Vy— <br /> f Z).4/u5circ/ �/<s <br /> City,Sta ,Zi ode <br /> City, Zip Cod I <br /> �i !ode <br /> - oras /S'- <br /> Telephone Telephone C7Q <br /> Permit(s)Applied for: '4&e,5h� <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> Privy �— Subdivision m <br /> Structure Use: /G' �0 ��U�rll'� CSN `A3Q^�k y��d T <br /> (family homelcabin, garage, addition,etc.) o v° <br /> m <br /> Directions for plot plan drawing: 7 <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. rT <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 /> 6. onon e sine o isormas on statement. 3PLOTPLAN <br /> o N <br /> Z v <br /> o n <br /> See gll P/0- " NA-) � �I'l� <br /> t = <br /> 1 5 <br /> 0 <br /> _ <br /> _ <br /> 0 <br /> N � <br /> O <br /> Z <br /> 1 O <br /> lord <br /> s ra he s mac( So Lane CausQ �^ ��f f- <br /> c�m mc>, o'.c°v <br /> low <br /> d <br /> o): y <br /> m <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 b ,� <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 includin an accompanyingschedule and I further declare that I recognize that O <br /> PP li 9 Y ) t p l <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 may be a result of the County of Burnett relying on this information I am providing m <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 4/RJG✓ S(r(�/�'� ON /Y'</ ✓/l P.e� L. ��J ��' <br /> (sig u of <br /> owner or �'Iciinng contractor) (� (date) <br /> ZONING ADMINISTRATOR <br /> / ' / <br /> CNN N Nm <br /> TOWNSHIP PER TS MAY BE REQUIRED c l o c o m <br /> 00 000V) <br />