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Burnett County Office of Zoning Administrator w m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> 0 <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 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. v <br /> 'JEQTr°/r1 T[e �'C/SSS CBL'�6 a ' _ 0 <br /> OWNER(Please Pr- t) Contractor or Surveyor or Agent o � M <br /> Address Address <br /> i2oqNpy1z-v A--/ <br /> City,State)Zip Code City,State,Zip Code <br /> X6 2c <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition — Moving o <br /> Sanitary Camping Unit 0 o <br /> Privy Subdivision 5 <br /> 7117 <br /> Structure Use: <br /> (family home/cabin, garage,addition,etc.) o v <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 J <br /> the owner. <br /> O <br /> description on the side of thisform) as on tax statement. O <br /> PLOT PLAN o N <br /> Z Q <br /> o n <br /> Q � <br /> N <br /> O <br /> 7 <br /> nll" <br /> I <br /> I <br /> P- IWM06L Dfauj N// <br /> 0 <br /> N I' <br /> O n <br /> O I[` <br /> O <br /> N � <br /> O <br /> aZ <br /> Z <br /> o <br /> Z <br /> D <br /> 71Nv(nr D> <br /> M a =.mm 0o.cm <br /> n cr'< o c o n= <br /> m n� —nm ^;ate <br /> o < d Cm o Z X <br /> T � m0Mm <br /> 0 <br /> T. .2 1 <br /> cz: m <br /> «r j cz; m <br /> c = € O <br /> Doo: <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 /> A :information contained in this application(including any accompanying schedule)and I further declare that I recognize that <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 a <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 /> f � <br /> SIGN HERE " 7 <br /> (si re of o ner or ilding contractor) (date) o o <br /> ZONING ADMINISTRATOR <br /> �7� IJ N O IU T <br /> TOWNSHIP PERMITSmAVIRE REQUIRED N o1 m <br /> 00oo oo�fA <br />