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Burnett County Office of Zoning Administrator w m o oz <br /> APPLICATION FOR — LAND USE — PERMITS <br /> !J 1 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 y <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- 3 n 1 <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. m w <br /> Sosepb, S �►�tn ©Scams Q-84 e <br /> OWNER pPlease Print) Contractor or Surveyor or Agent n F <br /> R-T l QXtt1 A n w ; <br /> Address Address V, = 1 <br /> Fre�eY;r✓ L.�:S - �'�( 5137 <br /> City,State,Zip Code City,State,Zip Cod 1 <br /> 11 E-14--) S ! 70 r,.1f-0.y�}.� (Ayim W , o� <br /> Telephone Telephone ' �^ <br /> Permit(s)Applied for: Q` <br /> New Building Filling/Gradingr- <br /> Addition Moving O <br /> Sanitary Camping Unit C� <br /> Privy Subdivision o _ 1 <br /> J <br /> N <br /> Structure Use: ° <br /> (family home/cabin, garage, addition,etc.) Z o <br /> P D <br /> A <br /> 1. Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North(N). o C <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 S <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 /> 0 <br /> A" a <br /> a \,,,, &I Z <br /> I <br /> rn <br /> Q <br /> N <br /> O ° <br /> J <br /> N8 <br /> V <br /> J v <br /> m Od• n <br /> v o <br /> w . J <br /> rye rixa, 00 0 <br /> Z <br /> P <br /> Z <br /> U4-1-1 LJ.4- 1 C6 -tto ko-S 1a 6e <br /> fill <br /> ''//11 2 Sv_.e-cC� cam {-ems �sor in d >a�'v <br /> M w� - 1 1 o//6/ �[�A m a - n o a 70 <br /> r a a <br /> 15 ✓e�l(G a c� y z _ <br /> z o; 1 <br /> o J ; <br /> co <br /> a 21 In <br /> o c C <br /> I(we)declare that this application(including any accompanying schedule)has been examined by me(us)and to the best of <br /> my(our) knowledge and belief it is true,correct and complete. I (we)acknowledge that I (we)am(are)responsible for the m <br /> detail and accuracy of all information contained in this application (including any accompanying schedule) and I (we) O <br /> further declare that I(we)recognize that this information I(we)am(are) providing will be relied upon by the County of Bur- <br /> nett Wisconsin in determining whether to issue a permit. I (we) further accept all liability which may be a result of the <br /> County of Burnett relying on this information I(we)am(are)providing in this application. I(we)agree to permit county offi- <br /> cials charged with administering county ordinances or other authorized person to have access to the above described pre- <br /> mises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HERE N <br /> (si u of owner or i Ing contractor). (date) E o ` o <br /> ZONING ADMINISTRATOR w-n <br /> cNnNf ooam <br /> TOWNSHIP PERMITS MAY BE REQUIRED o0 0 oovmi <br />