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C1 ) �' o <br /> W <br /> Burnett County741D Co. Rd. K. , #102, siren, wl 54872 Office of Zoning Administrator - 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 'z ui _ <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 n <br /> tions of the State of Wisconsin. p <br /> N d <br /> 13oB FK���R r�u�l� <br /> n � <br /> O NER(Please Print) Contractor or Surveyor or Agent m <br /> 2 In CArtIJoN FA is �LVD <br /> C./d ress Address <br /> E03 <br /> CityraState Zip Co a City,State,Zip Code <br /> ��. - <br /> Telephone Telephone <br /> 175- <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit n o <br /> Privy Subdivision .`.' r. <br /> w1 o r <br /> � <br /> _ <br /> ON <br /> Structure Use: I—PJRQ "a- <br /> ( a ily hometcabin,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 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. <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. 6. Provide legal land description. n <br /> 0 <br /> PLOT PLAN <br /> v N <br /> c <br /> Z v <br /> P a <br /> y. <br /> so <br /> e <br /> o <br /> J <br /> IN <br /> J <br /> w <br /> N � � <br /> O <br /> ZN \� <br /> Z <br /> O <br /> Z <br /> l �1n <br /> v 1 <br /> V)Ar D D WAD <br /> myoO J O <br /> Z <br /> O J N: <br /> wi m <br /> 0 ; <br /> 0 : 0 [ O <br /> I declare that this application (including an accompanyingschedule has been examined b me and to the best of m o c C <br /> PP (� 9 Y ) Y Y E y <br /> knowledge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy <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 oo <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 <br /> N <br /> N <br /> SIGN HERE <br /> (signL4,e of wner orb g contractor) (date) <br /> o: o <br /> o: b <br /> ZONING ADMINISTRATOR o: o <br /> T <br /> TOWNSHIP PERMITS MAY BE REQUIRED bbbm <br /> 4g80050000 <br />