002-109-21-1700-LUP-2004-042r
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Application for Land Use Permit (*Non-shoreland*) o o `-3"
County of Sawyer � �
PO Box 676 - Hayward WI 54843
715/634-8288
*Property that is not located within 300' of a creek, river or stream or within 1000' of a
flowage, lake or pond or does not have any of the above waterbodies located within
the property's boundaries.
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT—USE BLACK INK OR PENCIL 1'
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Owner -' ' ' Builder c: .
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Mailing Address Mailing Address ?v O
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City, State, Zip City, State, Zip
Daytime Phone Daytime Phone �
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Additional Information: Zone District: �
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Lot Dimensions:
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Date lot was created: Acres: �%. ' '= / � n �
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Is there wetland near the proposed structure?If yes, how far ^� �
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Building Land Use Floadgtain:� j �es ((�J No `� .
(�,�New ( ) Filling �
O Addition O Dredging Driveway access off of a(Check one): �
( ) Alteration ( ) Grading ( ) Private Rd �) Town Rd. o
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy N �
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Primary Structure Accessory Building Addition � °
welling ( ) Garage-attached/detached ( ) Deck W
(�Year round O # of car stalls O Porch �
) Seasonal ( ) Storage Building ( ) Enclosed �
O Frame built on site O Screenhouse O Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen g
( ) Mobile/manufactured ( ) Other ( ) Bedroom R�
( ) Other primary structure ( ) ( ) Relocate/enlarge � A
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AdditionalInformation: �' �
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Type of Construction: �
( ) Frame ( ) Log �Pole/metal ( ) Block ( ) Concrete Q�
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( ) Other
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Construction Cost: Primary Structure $ oC - � — � �
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Accessory Building: $ Addition: $ � r�
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Deed: Vol 8a3 Pg 3v� Certified Soil Test# oa -:�a� � z
CSM: Vol Pg Lot# Sanitary Permit# �</ -Qaz/ � %�
Plat Envelope Or: �, ��
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Condo Vol Pg Year Installed: c�
Aff of ex septic Vol Pg Owner When Installed: � �
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Previous office approvals/actions: 'C'
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Variance: # LUP: # SP: # CUP: # `
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Inspection Report: # Change of Zone District: v
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Describe the construction using these columns.List the dimensions of each structure in a separate '
column.List each story,each addition,each alteration in a separate column. - ,
#1. �2. #3. #4. ,
Size �i ft.wide fr.wide ft.wide fr.wide •
�j l) ft,long ft.long ft.long ft.long
Floor area rd ry a sq.ft. sq.ft. sq.ft. sq.fr. ��
Hgt.from gade�_to peak ft.hgt. ft.hgt. ft.hgt. �
Stories�� stories stories stories
#of bedrooms�_ i
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Fire Number and Name of Road `rl �✓f
1. Enter lot dimensions and indicate north by arrow. Signatu�e of Owner or Authorized Agent:
2. Indicate the location and size of the requested construction �i,�(�- - �� =� �^��� ��l l��' ��
SignaNre � �. �(�•;�--�
activities. • ,/ � �
PnntName: �i L�� �� �_l;/;/?Gill "' � ���?�,
3. Also,1ndlCate tlle LoCBtlon Nld d1StanCe t0 tlle We��, The above certifies that ihe listetl information and intentions are
true and corted.,that all work shall be pedormed in compliance
Sept1C tank and dI'ainfleld,wetland azeas,lot Ilnes and to tlle with the requiremenis of the Sawyer County Zoning Ordinance
and Ne laws and regulations of ihe State of Wisconsin,and if
CCritCI'l1RC Of tllE I'OaC�. acting as owner(s)agent has the permission of ihe owner�s)to
perfortn the work requested on this application. The above
personsls hereby give permission for access to ihe property for
onsite inspec6on.
Permit fee:$ o?C''- �
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Issue Date Signature ofIss ent
Y I I(p h''��'� �('i a�J 50%Rule: Average Road Setback:
Expiration Date
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Office Comments: /a� e-� M.o v�`ti s^
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