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r' <br /> Burnett County Office of Zoning Administrator m -00 0 <br /> APPLICATION FOR — LAND USE — PERMITSw 3, o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and v y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of 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 n <br /> bons of the State of Wisconsin. or <br /> 1 [ r m o <br /> ( j m <br /> OWNEee(Please Pri t) , f, f Contractor or Agent o <br /> Address Address <br /> ( C <br /> j� � S' b'• t l-e.,- �� � OO I O j.f 4f C1 .:.i(4 4� . .l• r.,� � '.. :"J .� <br /> City,State,Zip�Cod City, State,Ziy Cgde <br /> A� t b <br /> Telephone Telephone `\ <br /> Permits)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o t <br /> Sanitary Camping Unit o <br /> Privy Subdivision m <br /> 30K3 ,62 <br /> 0 <br /> Structure Use: <br /> (family homelcabin,garage,addition,etc.) Z.0 <br /> v \fJ <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). m <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. p <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and dated by N <br /> the owner. O <br /> 6. rove a ega escrip ion on the side of the form as on tax statement. 3 <br /> PLOT PLAN P r 'R c <br /> o n <br /> o <br /> a (� N <br /> ki t-1 0 <br /> tJ 7 0 <br /> N <br /> � i r <br /> j n <br /> ��\ m <br /> N <br /> l <br /> _ ( Z <br /> y ,r <br /> r <br /> 17 In vtnrDDW� <br /> O0 > 3 <br /> ANy �m <br /> 0 0 : 1 <br /> O N <br /> m <br /> 00: c C <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 n m <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <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 <br /> person to have accesp to the above descrdbed premises at any reasonable time for the purpose of inspection. <br /> T <br /> N <br /> ' N [ <br /> SIGN HERE <br /> 'fb ...w J � <br /> `� lC'rC7 <br /> _u o <br /> ,�® a'tu P owner or ildi g contractor) (date) ` � <br /> o; o <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMITS AY BE REQUIREDp <br /> p <br /> LV I . . <br /> (min o v <n o v. <br /> b0000 0 <br />