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11 <br /> Burnett County Office of Zoning Administrator rn T <br /> m m o <br /> APPLICATION FOR — LAND USE — PERMITS 3 <br /> 0 <br /> TO 'HE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and y <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 <br /> tions of the State of Wisconsin. <br /> _ <br /> OWNER lease Print Contractor or Surveyor or Agent o. <br /> Ave ,U W. <br /> Add�yssO _jt4 sir mN 65'C' Address <br /> City, State Zi ode C/ City,State,Zip Code <br /> 4150! -y`d`7 -028$,583 y 3 <br /> Telephone 9/5—635 - 7770 %&N) Telephone w <br /> Permit(s)Applied for: <br /> New Building Filling/Grading <br /> Addition Y, Moving o <br /> Sanitary Camping Unit <br /> 0 <br /> Privy Subdivision O <br /> S{ � 0 <br /> � <br /> Structure Use: o207I , <br /> U) <br /> (family home/cabin, garage, addition,etc.) o o (f, <br /> a .\ <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. 9k" 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. }h` <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 /> f0 <br /> 6.Povealegal description on the side of this forml as ontax o <br /> LOTPLAN' <br /> 3 <br /> lapel t 1AGlw� �,. o <br /> FA0 <br /> ,Doi O <br /> i O <br /> Cmm <br /> I o <br /> Cp <br /> O <br /> oa <br /> See Pe'rM.+ Ng <br /> o <br /> m <br /> Z c <br /> M <br /> D <br /> M 0)-0 mr-DD do-a <br /> rn <br /> m arc nm »ay <br /> ` O <br /> I declare that this application (including any accompanying schedule) has been examined by me and to the best of my �o <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 an accompanyingschedule and I furtherdeclare that I recognize that <br /> PP ( 9 Y ) 9 m <br /> this information I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a oA <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 c <br /> person to have ccess to the above described premises at any reasonable time for the purpose of inspection. <br /> G/ m <br /> O m <br /> SIGN HER <br /> (sl a of o e r wilding contractor) (date) <br /> o; o <br /> ZONI AD ISTRATOR <br /> J N O N N T <br /> TOWNSHIP PERMITS MAY BE REQUIRED yicn<ncno SN. <br /> 00000 <br /> y <br />