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Burnett County Office of Zoning Administrator m M0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <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 `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. p <br /> I t9 N 0 l-t-Aj-C <br /> o <br /> OWNER(Please Pri Contractor or Surveyor or Agent <br /> ?y�{U S� '4o . S'o m <br /> Pores r / Address <br /> yCCGZ �t 1 At1anK _ -s-CIX) <br /> City,State,Zip Code City,State,Zip Code I <br /> Telephone Telephone <br /> Permit(s)Applied for: Q <br /> New Building FillinglGrading <br /> Addition Moving o <br /> Sanitary _ Camping Unit 0 o <br /> Privy Subdivision 0 <br /> Structure Use: (IV I f\.)L' v <br /> (f mily homelcabin, garage, addition,etc.) o o <br /> v <br /> m <br /> Directions for plot plan drawing: �� r <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 A <br /> the owner. <br /> 0 P- <br /> 0 <br /> PLOT PLAN 3 <br /> a N <br /> Z c <br /> o a <br /> y <br /> l O <br /> O <br /> V� <br /> a <br /> h <br /> N p <br /> N <br /> N � <br /> n.. <br /> Z \ O <br /> O <br /> � Z <br /> OL C' <br /> d �0aWIn <br /> m a ' 0saM <br /> WD. <: w mo�� <br /> N O <br /> Z O <br /> O > : <br /> M <br /> no D <br /> o i c ' C <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my — o: m <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 ) 9 <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a <br /> permit.I further accept all liability which may be a result of the County of Burnett relying on this information I am providing n <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 /> SIGN HERE <br /> (sig u of owner o ng contractor) date) o o <br /> ZONING ADMINISTRATOR -� �-" ` o o <br /> m <br /> TOWNSHIP PERMITS MAY BE REQUIRED "PRPPM <br /> 00 0000 <br /> oog0000fA <br />