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Burnett County Office of Zoning Administrator d _ -- Z <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z m <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- 3 a <br /> tions of the State of Wisconsin. ,. I t,1 <br /> m v V <br /> F: tku l�zbOicil� A-�crber <br /> OWyN� I�ase Print I I �� Contractor or Surveyor or Agent o <br /> ooCC l0 rri d <br /> Address Address m �) <br /> r2 oS _L) r W►a' S S'//3 <br /> Cit ,State,Zip Code City,State,Zip Code t <br /> a I ) 3 I ' tos- � c� <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building rub Q Filling/Grading <br /> Addition Moving p <br /> Sanitary Camping Unit O <br /> o <br /> Privy Subdivision o `• <br /> I N r <br /> Structure Use: <br /> v <br /> (family homelcabin, ara a addition,etc.) 0 0 <br /> a <br /> m <br /> Directions for plot plan drawing: a <br /> 7. 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 /> , <br /> river or stream, if applicable. trS zt <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. O + <br /> isora6. a legalescrip ion on a side o s on saemen aPLOT PLAN bO J w <br /> N Z J c <br /> o m' <br /> n <br /> ¢ �� y <br /> yoTqq ' =NLry <br /> I i tc° > <br /> i C C m <br /> �) m <br /> I N r <br /> O <br /> C0F �I r <br /> A � <br /> n V rl <br /> ST <br /> a� Z <br /> 0 <br /> Z <br /> q�tA <br /> rtr <br /> f�a� <br /> M m y m r D D co-0 <br /> m a =am ';a� <br /> N p Oj n <br /> O m•z <br /> USS LLvt—F� vi n E D <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 S <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that lj I A m' m <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 ' n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> SIGN HERE ' U-1 I//. <br /> (si atur of owner or Iding contractor) (date) „ [ <br /> ZONING ADMINISTRATOR -' GZf/� o? o <br /> i TOWNSHIP PER TS MAY BE REQUIRED cd N N T T O f O <br /> 00000 0 <br />