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Burnett County Office of Zoning Administrator w 'D1 Z <br /> j N O p <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> TO THF.ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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 n <br /> ons of the State of Wisconsin. <br /> 0�K ��oatGh�N y ° <br /> OWN1E9q(PI ePrint a f <br /> �! ��S �ePir / 3807 Gt,1, Contractor or Surveyor or Agent _r <br /> ( ,Dear ) <br /> Ad ress �� Address n <br /> NM V <br /> City,State,Zip Cade/ City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for. <br /> New Building Filling/Grading <br /> Addition Moving o <br /> SanitaryCamping Unit O <br /> 0 <br /> Privy1J Subdivision <br /> $tNCfUfB Use: O o <br /> V <br /> (family homelcabin, garage, addition,etc.) o o <br /> m <br /> Directions for plot plan drawing: z <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. o <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. t�• <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 /> LO �?XA a legal description kon the side of thisform) as on tax statement- 3 <br /> a U <br /> o a <br /> pe/l i - rs-I- was <br /> Pn^�a-r -4--d <br /> I <br /> 419kill,ts C <br /> 71141 - <br /> N <br /> I o <br /> /sem o <br /> w <br /> 00 <br /> P <br /> m <br /> see- 4 j o <br /> o <br /> Q <br /> 499 r✓ Y CNe) r <br /> �s cy .x4 <br /> 77� Mm n rDDW o <br /> ,P ci a = o a= <br /> •�0�� m a ay =a9 <br /> 9 < C N 55-M <br /> T : `2NO =n <br /> Z O <br /> O = <br /> m <br /> O <br /> Qo c : C <br /> I declare that this application (including any accompanyin du e) 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 <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that <br /> PP ( 9 Y ) t i C <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 aplplication,4 agree to permit county officials charged with administering county ordinances or other authorized a <br /> person to have c s to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> p q m <br /> SIGN HERE <br /> (si ure oillowner o uildin contractor) (date) N <br /> ZONING ADMINISTRATOR <br /> OWNSHIP PERMITS Il REQUIRED 'd. it N o o �m <br /> 0000c5 U) <br />