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Burnett County Office of Zoning Administrator m o a <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m r <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- 3 n ,v <br /> tions of the tate of Wisconsin. = o <br /> O <br /> OWNER(Please Print) Contractor or Surveyor 6r Agent o <br /> m <br /> Address I�^y LAddress' v yj <br /> City,State,Zip Code City, State,Zip Code <br /> x _ <br /> Telephone G 3 3Cf Telephone -. <br /> Permit(s)Applied for: _ <br /> New Building Filling/Grading <br /> Addition Moving o �' <br /> Sanitary Camping Unites n o <br /> Privy Subdivision 0 <br /> m r <br /> 0 0 <br /> Structure Use: �tAMPi ty� I1 Ai I I RiP, LCT— v <br /> (family home/cabin, garage, addition, etc.) o 0 <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. 0 <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 /> n <br /> 6PLOT PLAN a legaldescription on a side o is form as on tax statement. 3 <br /> 9 (n <br /> C <br /> ✓,\ y <br /> J <br /> Jul <br /> 0 <br /> T y <br /> T� z a <br /> N o <br /> I z <br /> �I D <br /> u D D S , <br /> m <br /> n X <br /> ic <br /> 0 J f0 <br /> Z p': �� 1 <br /> — C, t �enlivaS � rm `J I :$(✓"7�v 1 13i "] 2 i 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 )=: m <br /> PP ( 9 Yaccompanying 1 g n <br /> information contained in this application includin an schedule and further declare that I recognize that <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 m <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 ve described premises at any nable time for the purpose of inspection. <br /> m <br /> SIGN HERE <br /> (signaj,j of owner or iiing. trraacc�tor)r) (date) " Z4 <br /> ZONING ADMINISTRATOR l/ <br /> o: o <br /> TOWNSHIP PERMITS MAY BE REQUIRED oN uN i o�"m <br /> oo��oo(A <br />