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}Y,. t.v»Lf,I <br /> Burnett County APPLICATION <br /> ren Office of Zoning Administrator / 0 v 1 z <br /> TO THE ZONING ADMINISTRATOR:ICATIONerFOR hereby LANDUSE^for PERMITS work described and = b <br /> 0 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- ' 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. <br /> A/yan A . Co nor / t//Z. c <br /> OWNER <br /> (Please <br /> Ple s pPrint) Contractor or Surveyor or Agent o J� 0 <br /> Address Address <br /> City,State,Zip Code City,State,Zip Code , <br /> .57'//u/esi'ry Ky .?.SO b1Y ) <br /> Telephone Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit <br /> PrivySubdivision 0 < (1� <br /> Structure Use: r�� X- 3a <br /> (family home/cabin, garage,addition,etc.) Z a <br /> 0 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. o <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 /> PLOT lot LILGAL UlLbuffirlium PLAN un the side of thisform) AS ON TAX STATEMENT. <br /> Z_ c <br /> o' <br /> o n <br /> G <br /> (j, <br /> T� Z <br /> W ;- o <br /> 7 <br /> N e <br /> O <br /> o <br /> m i \ <br /> O <br /> y --I <br /> -� m <br /> j of r_l <br /> ` \ Z. <br /> 1 U <br /> JJ N�Nr DID <br /> m n� dam aEn <br /> SL' c0'9 <br /> � O i .2 <br /> w! m <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 o � ` m ml <br /> Information contained in this application(including any accompanying schedule)and I further declare that I recognize that ` '• p <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a g <br /> permit.1 further accept all liability which may be a result of the County of Burnett relying on this information I am providing i 1 i i m <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ' n <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> / m <br /> SIGN HERE 6_41&�Z <br /> (SigAaUffe of owner o building contracto (date) IJ <br /> ZONING ADMINISTRATOR P2 <br /> OWNSHIP PERMITS AY BE REQUIRED rn o o m <br /> $$$$ m <br />