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Burnett County Office of Zoning Administrator m m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 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 Wicousin. — O - <br /> w d <br /> ��G��Y a o <br /> Cont r t r or Sury yor Agent £ <br /> OW ER_ lease Print) f� _ � l /�jC� C,/� d m <br /> �45 � lae le�n� L '( d <br /> Address , L <br /> Address - -� L <br /> dun ( I F1 �_ R�3�i ) IHn�h G % �9 �� <br /> City,State,Zip Code City,State,Zip Code 2 _ <br /> Telephone Telephone <br /> Permit(s)Applied for: 4n <br /> New Building woe�jB OV X� Filling/Grading <br /> Addition Moving <br /> Sanitary Camping Unit o <br /> 0 4 <br /> Privy Subdivision w <br /> Structure Use: <br /> (family home/cabin,garage,addition,etc.) o ° <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). r- <br /> 3. <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. <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 /> rove a ego escrip on on a si e o s i ❑rm as on ax statement. 3 <br /> PLOT PLAN m 90 <br /> Z a <br /> P _a <br /> 145. <br /> ___. N <br /> -- T j <br /> 11I <br /> sl9" U� <br /> N <br /> a ° <br /> o <br /> c ril <br /> N V\ <br /> Z <br /> r I' <br /> o a� m c rn <br /> �NNnnWrn <br /> m <br /> c c rn ? momm — <br /> Z O: '2 : 1 <br /> m <br /> o <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of myS, 'm Fa <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 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 <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. m <br /> m <br /> m <br /> 9IN7 <br /> SIGN HERE ` --y <br /> (signs of ow er wilding contractor (date) o o <br /> i o i O <br /> ZONING ADMINISTRATOR <br /> WNSHIP PERMITS MAY BE REQUIRED m <br /> i 0000SogV1 <br />