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f , <br /> Burnett county Office of Zoning Administrator U - -. 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3 _['fo TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z ylocated as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur-nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3tions of the State of Wisconsin. <br /> /u /� ey G.� �. CIOivSi.� r- G/� m <br /> OWNER(Please Print) Contractor or Surveyor or Agent o � <br /> a91,19 46�e�; LR-.('F //IO m <br /> Add s Address -1 <br /> City,state Zip Code City,State,Zip Code <br /> 1v/� - 770 - �/�'� I /0 <br /> Telephone Telephone C <br /> r <br /> Permit(s)Applied for: <br /> New Building X Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit @ ct �T <br /> 0 <br /> Privy Subdivision 0 ,<.- <br /> w <br /> structure Use: � Q <br /> (family home/cabin, garage,addition,etc.) o 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). <br /> 3. Show the location of any lake or flowage-if within 11100 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. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by s <br /> the owner. <br /> O <br /> 0 <br /> PLOT PLAN 9 <br /> a y <br /> Z Q <br /> 1514 <br /> / <br /> w>c <br /> t <br /> Cn <br /> ADO67 , <br /> 0 <br /> N <br /> O <br /> T <br /> N <br /> Z <br /> O <br /> 2 <br /> I <br /> Nc�0 W 0 cm <br /> o Q< > > o -. <br /> 5 m C <br /> 0 <br /> o <br /> 0o: 00 <br /> Z <br /> n� 2 m <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.I acknowledge that I am responsible for the detail and accuracy of all _ m <br /> information contained in this application(including an accompanyingschedule and I further declare that I recognize that A <br /> PP (� 9 Y ) 9 � C <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 o <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 /> SIGN HERE <br /> (signature of owner or building contractor) (date) <br /> ZONING ADMINISTRATOR - '-F'lLb •) o: E ` o <br /> .. ,. e�Y/TOWNSHIP PERMIT$'MAY BEREQUIRED o� �Onu,2, lnoo <br /> 000000 <br />