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"" iYVl l-IIWCb 6G 111 "IJUUIIb U11 LleCLL1C LOm. /1J-4bJ->5/1*� <br /> Burnett County Office of Zoning Administrator m 'D Z <br /> APPLICATION FOR - LAND USE - PERMITS W A <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z w -17 <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m c <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula. m 6 <br /> tions of the/State of Wisconsin. _ o. ZE <br /> w <br /> OWN�E�R�(�Pleas; P�r^lntj) Contractor or Surveyor or Agent o. F <br /> Address = _I, ;oJ'A'��Itl,vtrl ?Got S:i to (v <br /> City,State,Zip Code City,State,Zip Code <br /> '/,L - "y-gy-2r'r 1/ <br /> Telephone Telephone 04) <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving <br /> 0 <br /> Sanitary Camping Unit <br /> Privy O Al) <br /> Subdivision o' <br /> N <br /> Structure Use: f � <br /> (family homelcabin,garage,addition,etc.) Z o <br /> P a <br /> Directions for plot plan drawing: fD <br /> a <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). 4/0 <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 PLAN o <br /> \ o u <br /> \ z <br /> o n <br /> Cn <br /> r <br /> p'h in <br /> p o <br /> n <br /> t1 \ \ I < <br /> r \ H <br /> CD <br /> a <br /> N <br /> � <br /> m <br /> O <br /> w � <br /> - T W <br /> N <br /> 2 <br /> I JJ <br /> Ico <br /> Go <br /> o <br /> C n v o o <br /> n Nm O O O O =40 <br /> m <br /> p o c C <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 ° ' <br /> Information contained in this application(including any accompanying schedule)and I further declare that 1 recognizethat A m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to Issue a ' ` s <br /> permit.1 further accept all liability which may be a result of the County of Burnett relying on this information I amrovidin <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized m i <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. ' •' -• <br /> SIGN HERE <br /> (signs re of owner q Iding contractor) (date) <br /> J i <br /> ZONING ADMINISTRATOR p o <br /> LL <br /> OWNSHIP PER ITS MAY BE REQUIRED d J N O J N <br /> Op�tpn tpT Npp OU <br /> (� 0000000 <br />