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Burnett County Office of Zoning Administrator d M a Z <br /> APPLICATION FOR — LAND USE — PERMITS d 3 <br /> TO THE,ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m 1 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 0 c NU <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. (1 , <br /> tions of the State of Wisconsin. / .� o <br /> T -rn sy /�Si✓N¢ > iso i �C �,A `s L° n � o <br /> OWNER(Please Print) CC�actor o Surveyor or Age9t n <br /> L1 11' ST /C� p-3 7 i E% ti4 L <br /> Address Addr / �" `� I <br /> -C �f �irrf <br /> S-- 1 ✓ �� /�'S 55��3�7 "C <br /> City,State,Zip Code City,State,Zip Code VQ <br /> �7 <br /> Telephone Telephone t ' <br /> Permit(s)Applied for: ''// <br /> New Building ^ FillinglGrading <br /> Addition Moving p r <br /> Sanitary Camping Unit <br /> Privy Subdivision 0 Q <br /> Structure Use: <br /> (family home/cabin, gars e,addition,etc.) 0 0 <br /> D <br /> N <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). r�-.� <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.6. rLOV100 r <br /> legal description on the side at isterm) as on tax statement. <br /> o <br /> PLOT PLAN3 <br /> v to <br /> Z c <br /> sa �y <br /> _ o s <br /> �— oe3 <br /> � o <br /> o � <br /> 24 <br /> 0 <br /> r <br /> o <br /> Z <br /> 1 <br /> I <br /> 7M.. U) coC' =0 rD DEm <br /> a <' " cm o`o3 <br /> Z N `2 y 0 7 b <br /> O O ' � z : <br /> M <br /> f O <br /> 40; <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 711 <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that n <br /> PP li 9 Y ) t O <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 <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized c <br /> person to have access to the abo a described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE <br /> (sign of ow er uilding contractor) (date) [ j, <br /> o: o <br /> ZONING ADMINISTRATOR WrI: o o <br /> TONSHIP P Mcn�n "ITS MAY BE REQUIRED NNOI + Nm <br /> (r}.��7, 88 <br /> "00000$oftnmp <br />