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nn C oat f <br /> Burnett Cgunty Office of Zoning Administrator d M0 0 <br /> APPLICATION FOR - LAND USE - PERMITS3, <br /> d O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 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 a <br /> tions of he State of Wisconsin. m o <br /> OWNEIVlease Print) Contractor or Surveyor or Agent <br /> m � <br /> io <br /> Addressr �� ( i1 AddressJt& — <br /> City,State,Zip Code IN City,State,Zip Code <br /> Telephone Telephone -C <br /> I <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> 0 4 <br /> Privy Subdivision 'm <br /> 0 <br /> Structure Use: <br /> (family homel i ,garage,a itio ,etc.) 0 0 <br /> _ m <br /> Directions for plot plan drawing: (JJ <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). lX-1 <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, f <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 y <br /> the owner. <br /> 0 <br /> e legal description on the side of this form) as on tax statement. o <br /> to �4Xrr3 a <br /> Z <br /> o a a <br /> � y <br /> I <br /> J <br /> N �0 <br /> A <br /> Z I(i' <br /> m I��111"v(((vVvv\\\v <br /> �\ Z <br /> v O Z <br /> f� jl <br /> t' J <br /> m c<mooLcm� <br /> A Q< > D0n_.m <br /> m Zoo Po <br /> Z o E Z : 1 <br /> o <br /> co i i A <br /> ;b s fJ <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 /> A <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 V I 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 n <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. <br /> T <br /> SIGN HERE p, <br /> (signay re o ner or builn contractor) ( ate) o o <br /> ZONING ADMINISTRATOR .I' ���. <br /> N N O N N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED n gn n ur o o v m <br /> oocoobo <br /> 0000000fA <br />