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6f-� r(`,i r i ( 1 <br /> Burnett County Office of Zoning Administrator d -00 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v V t� <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements, the Bur- m m <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 tate f Wionsi <br /> 30If y <br /> OWnN/ER(Please Print) Contractor or Surveyor or Agent o �: <br /> AdAresAddress <br /> qp L ) <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving 4 <br /> Sanitary Camping Unit 0 o " <br /> Privy Subdivision m »- <br /> Structure Use: e ) � <br /> (family home/cabin, garage,addition,etc.) 0 0 <br /> v <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. <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 /> O <br /> $LOPf 3PS'Xrb <br /> de legal description (an the side of this form) as on tax statement. 3 <br /> v N <br /> c <br /> Z a <br /> o n <br /> c <br /> 0 <br /> O <br /> J <br /> C) v <br /> s <br /> 0 <br /> J <br /> N <br /> J <br /> 0 <br /> n <br /> ZZ <br /> V Z <br /> p <br /> � nsi , tela or- press u r(P- �s�- L <br /> --I--I�I /�U� r I I �"�- �%o d - <br /> C�L —t-- L(S -61 I I f7? r I �> <br /> (J lid 1(i P� 1 4G NemOm Q >> c <br /> a <br /> N y0 J <br /> O O <br /> c m <br /> v <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my o <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all m <br /> information contained in this application(including an accompanyingschedule and I furtherdeclare that I recognize that O <br /> PP relied <br /> 9 Y ) t 'o <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a o <br /> permit.I further accept all liability which may be a result of the County of Burnell relying on this information I am providing a <br /> in this application. I agree to permit county fts charged with administering county ordinances or other authorized <br /> person to have access to the above d scri d premises at 5py r sonable time for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> (sionCture of ownerAr building contractor) (date) <br /> ZONING ADMINISTRATOROn <br /> o; o <br /> TOWNSHIP PERMITS MAY BE REQUIRED �o ON <br /> 0000$p <br />