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� 1 <br /> Burnett County Office of Zoning Administrator m _0 o1 o <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING AINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m <br /> located as show .arein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- <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 /> 0 <br /> DUB"RSit-iO LOnVviF Se-LF N <br /> o <br /> O9E(Please Print) Contractor or Surveyor or Agent n <br /> 1 51 (2k hRI VF <br /> d <br /> Address Address I <br /> 1 A� 41S 4P,164rs it AlN 5'5-1 Z7 <br /> � o <br /> 4y,Stat ,Zip deCity, State,Zip Code <br /> i z,� Zip - f3cb9 i <br /> elephoo e-� Telephone <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Moving o <br /> Sanitary Camping Unit 0 O <br /> 0 <br /> Privy Subdivision <br /> r <br /> �- o <br /> Structure Use: `� 'l�6 v <br /> (family home/cabin, garage,addition,etc.) o 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. <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 /> O <br /> PLAN a legaldescription on e side o his form as on tax statement. 0 <br /> PLOT <br /> a m <br /> 2 Q <br /> P a <br /> c <br /> ( y <br /> O <br /> 0 J }� <br /> t � t <br /> 0 <br /> (> I <br /> CN <br /> C � m <br /> 0 <br /> Ply <br /> J <br /> J 3 <br /> o <br /> O 0 <br /> r <br /> Z <br /> 6� <br /> wwnacm <br /> 0 or= 00 a= <br /> m o.� -'am »ate <br /> 0 5' cwo'� 3 <br /> f/ 'Z' N 0 J(G <br /> M <br /> v : o O <br /> 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 /> PP (including Yaccompanying ) 9 J' n m <br /> information contained in this application includin an schedule and I further declare that I reco nize that a : p <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 <br /> in this application. I agree to permit county officials charged with administering county ordinances or other authorized ` a <br /> person to have access to the above described premises at any reasonable time for the purpose of inspection. <br /> m <br /> SIGN HEREX ` � <br /> (sign ure of owner or building contractor) (date) O o I o <br /> ZONING ADMINISTRATOR <br /> -t <br /> TOWNSHIP PERMITS MAY BE REQUIRED ^ c^ m <br /> (T!T fP N <br /> 000$ <br /> 611,UM) <br />