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Burnett CouAty Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. _ <br /> d o <br /> TO THE 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 <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 Wisconsin. m wv <br /> t / / C <br /> a w O <br /> OWNEC) '%R(Ple22Print) ((��1 � Contractor or Surveyor or Agent o <br /> �� <br /> m <br /> Address Address <br /> CAW <br /> City,State,Zip Code City,State,Zip Code <br /> "/ - / 1. <br /> Telephone Telephone c <br /> Permit(s)Applied for: <br /> New Building FillinglGrading J <br /> Addition Moving o <br /> Sanitary Camping Unit o <br /> Privy Subdivision N »' <br /> f�Nr � a <br /> Structure Use: hly v <br /> (family homelcabin,garage, addition, etc.) o 0 <br /> a <br /> _ m <br /> Directions for plot plan drawing: a <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NS)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. <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. (h7 <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. O <br /> ❑ de le al descri tion 0 <br /> LO �a q P (on the side of this form) as on tax statement. 3 <br /> a N <br /> C <br /> Z v <br /> o a I <br /> N p <br /> ? 1 <br /> VI <br /> I s <br /> N <br /> 6 <br /> O <br /> I`7 <br /> O <br /> 0 <br /> 1 <br /> N � <br /> D 0 <br /> Z <br /> O <br /> �1 Z <br /> m c dnacOm <br /> WD. <br /> a »'nm any <br /> Z N v� 0 <br /> T. <br /> ' ' nE y <br /> 2 m <br /> 0 � p <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 <br /> knowledge and belief it is true,correct and complete.1 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 a : � O <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <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 /> ' 4 io <br /> :N HER2r'� �� � <br /> (;14dat a of owns oil c tractor) (date) <br /> O; <br /> 9 ADMINISTRATOR <br /> n T <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O v +N m <br /> o$oo$ooM <br />