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Burnett County Office of Zoning Administrator Cn m o 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <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- <br /> tions of the State of Wisconsin. <br /> Pl-F a _ o I <br /> OWNER(Pleas7e Print)ylContractor or Surveyor or Agent <br /> SO, o <br /> #2 U <br /> / <br /> Address Address <br /> N/, v� >7ea /is , <br /> City,State,Zi Code ' City,State,Zip Code <br /> M/00 R61 -137 ' <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> Sanitary Camping Unit n o <br /> Privy Subdivision <br /> l I �, _ r <br /> Structure Use: <br /> � r! I ) �ICT(YLP J � o I/ <br /> (family home/cabin, garage,addition,etc.) 0 00 <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. <br /> n <br /> sform) as on tax s a emen o <br /> PLOT PLAN 3 <br /> a m <br /> 5 P e C[ E CcC l d Vc�cv >2+l o a <br /> Q <. <br /> �t <br /> _ C <br /> 0 <br /> co <br /> , <br /> O <br /> -c <br /> o v, <br /> J <br /> N <br /> O <br /> m <br /> T <br /> N <br /> P <br /> O <br /> D <br /> mvmra ou <br /> n Q<> > o <br /> m n� 'am n <br /> o < ' dCm <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 O <br /> PP ( 9 Y ) t a <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a c <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing w <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 lam'/L '��"` /�/%,y`�2- ell 9/Y <br /> (sjgatur f owne or building contractor) (date) i N <br /> ZONING ADMINISTRATOR <br /> TOWNSHIP PERMI MAY BE REQUIRED aOi j <br /> NV•P OtO O• <br /> 0 0 0 0 O <br />