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Burnett County Office of Zoning Administratora o <br /> APPLICATION FOR — LAND USE — PERMITS3 <br /> ,u o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z rn <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 Code,and with all other applicable County Ordinances and the laws and regula- <br /> tions of the State of Wisconsin. p <br /> y � <br /> UJI��low LQIp Q4A <br /> n O <br /> OW ER(Pleas Print) Contractor or Surveyor or Agent <br /> x <br /> Address �� 8o I Address \77 <br /> �QaCity State,Zi Code b City,State,Zip Code <br /> _I45 - X35 - 8-�81 _ <br /> Telephone Telephone / <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit o 0 <br /> Privy Subdivision ° <br /> 0 m r <br /> �/�M/�/w�1 Gn, 7L .r - e-, <br /> Structure Use: Q � <br /> 7 (family home/cabin, garage, addition,etc.) o o° <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 1000 ft. and the location of any river or stream- if within 300 ft. 0 <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 <br /> the owner. <br /> 6. isform) as on tax statement. o <br /> PLOT PLAN 3 <br /> v N <br /> Z `v <br /> o a <br /> ess 4w <br /> �Gre'p I�o�•sc ' <br /> � ff�l6fi <br /> 1 � <br /> 0 <br /> J <br /> WS 12jz C'�l�C�- �SU <br /> 0 <br /> cldn' 77? <br /> m co m no Ra S.m <br /> m a�`c 0.0 a a 77 <br /> ll a < ' mCmoJ3 <br /> Z y ayo �� i <br /> 0 0: <br /> n€ � ; m <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 /> information contained in this application(including any accompanying schedule)and I further declare that I recognize that ` a O <br /> Vv <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> N 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 m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized 9 n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> T <br /> SIGN HERE <br /> ( ' n re of owne uildi ng ontractor) (date) <br /> o: o <br /> o: o <br /> ZONING ADMINISTRATOR <br /> pNti N71 <br /> TOWNSHIP PERMITS MAY BE REQUIRED a b m o!n <br /> 00 $ <br />