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Burnett County Office of Zoning Administrator (n M 0 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 m -� <br /> located as shown herein.The undersigned agrees that all work shall be done in accords�ca with the requirements of the Bur- <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County 9ndinances and the laws and regula- 3_ n <br /> tions of the State of Wisconsin. p <br /> y d J <br /> M fiii A - + R -rJA L . ✓VJ/}NAEL a O <br /> OWNER(Please Print) Contractor or Surveyor or Agent <br /> VZ JS C.OLAMA CT. 0o 0 M <br /> Address <br /> Address AddI <br /> -ZA)I/C-Yt ('I f UV CF H7i- / X1'1 N SS 07h / n oCK-)City, State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> Permit(s)Applied for: 7C <br /> New Building FillinglGrading <br /> Addition Moving 0 <br /> Sanitary Camping Unit n G) <br /> 0 <br /> Privy Subdivision 0 <br /> /� rn r <br /> Structure Use: ✓�� L��r� v o <br /> (family homelcabin, gar , addition,etc.) o a <br /> m <br /> Directions for plot plan drawing: C1_..� <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). Q� <br /> 2. Show the location of the well(W),septic tank(ST),and drainfield (OF). <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, nl <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 /> PLOTrPLAN e e a description on a side o is form) as on ax statement. <br /> 3 <br /> v y <br /> Z Q <br /> o a <br /> �J y <br /> G 0 <br /> I � <br /> O _ ice\ <br /> 4 '4 <br /> /l I <br /> IV} N <br /> V <br /> n O <br /> 7 <br /> O <br /> O <br /> O <br /> R <br /> Z d <br /> z <br /> Ic <br /> M (Avco-DDW� <br /> m a� -'nm ,ay <br /> a <' °' Cmoo3 <br /> N 'Z N O 710 <br /> O 1 <br /> IT <br /> D <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my <br /> (Y1c i c C <br /> knowledge and belief it is true,correct and complete. I acknowledge that I am responsible for the detail and accuracy of all --.0 m <br /> A <br /> IT <br /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that 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 i i <br /> SIGN HERE— 7 <br /> (sign f owner or builntractor) (date) o[ o <br /> ZONING ADMINISTRATOR �2 2!��%%'-^��-�\ �JT E E o o <br /> �[ <br /> TOWNSHIP PERMITS MAY BE REQUIRED N N O J N m <br /> cn ul u,rno ornm <br /> 000000g <br />