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Burnett County Office of Zoning Administrator (n � 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> o <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 Cade,and with all other applicable County Ordinances and the laws and regula- 3 a <br /> tions of the State of Wisconsin. o Z. <br /> OWNER(Please)Print) _ Contractor or Surveyor or Agent o J <br /> Address Address <br /> A <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: 1 <br /> New Building Filling/Grading ` <br /> Addition Moving p 1` 11 <br /> Sanitary Camping Unit ct <br /> 0 <br /> Privy Subdivision 0 �- <br /> r <br /> o <br /> Structure Use: 6wb <br /> (family home/c in, garage,a iti n,etc.) o a° <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. 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, 0jriver 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 /> 6. Pluvide leyal description (on e side or tnis orm as on tax s a emen no <br /> PLOT PLAN 3 <br /> P m <br /> Z a <br /> o a <br /> N <br /> � O <br /> l <br /> a <br /> K G <br /> 0 <br /> N <br /> 0 <br /> O <br /> N � <br /> N <br /> Z <br /> O <br /> Z <br /> a <br /> 1 <br /> J <br /> M c- m o a c m <br /> n a 0a-.m <br /> m nom - m ^;ay <br /> a <= m m o 0 3 <br /> n E o om <br /> Z L. m2 : 1 <br /> 0 ' rn: <br /> �€ 2m <br /> N: 0 O <br /> o c C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my S: <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all <br /> PP (including Yaccompanying ) g ^ <br /> information contained in this application includin an schedule and I further declare that I recognize that Jv ' a : 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 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. <br /> T i <br /> yam' x _ i <br /> SIGN HERE_! � � � � "- �' <br /> (sig ature- o ner or build]• ontractor) ----- `: N <br /> ZONING ADMINISTRATOR o o <br /> n-1 <br /> TOWNSHIP PERMITS MAY BE REQUIRED " " j J" m <br /> N(T(T(TOOK <br /> 0000000rn <br />