002-940-21-5111-LUP-2004-317 'L_
Application for Land Use Permit(*Shoreland*) r ,�
County of Sawyer ° �
PO Box 676 -Hayward WI 54843 �
715/634-8288
*Property that is located within 300'of a creek,river or stream or within 1000'of a � �
flowage,lake or pond or has any of the above waterbodies located within J
the property's boundaries. 1
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT-USE BLACK INK OR PENCIL �
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O�oJ S ,�UR��S� 'TQ,NSTr�t Builder ¢ n' _
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Mailing Address Mailing Address � p �
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Cit 3tate,Zip City,S ate,Zip
/i 3`�— /7 L L �GD - �l 1— y'`�� � �1
Daytime Phone Daytime Phone Z
,�o u
Additional Information: Zone District: /V� � �1
Lot Dimensions: ���X yqSX�3`f� y�
Date lot was created: Acres: L� �7
Is there wetland near the proposed structure?If yes,how faz o
Building Land Use Floodplain:( )Yes (Xj No G
Q�New O Filling Chippewa Flowage:O Yes (1� No �
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading fiQ Private Rd O Town Rd. �
( )Moving On ( ) ( )County Hwy ( )State Hwy °Q
� ) � ) �
� o
N �j
N r
Primary Structure Accessory Building Addition o �
( )Dwelling ( )Gazage-attached/detached ( )Deck �
O Year round O#of caz stalls O Porch �, �
( )Seasonal ( )Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room �o
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen "
( )Mobile/manufactured ( )Other ( )Bedroom _
O Other primazy structure (� �✓}2 r�a O Relocate/enlazge p '
� � ( ) ( )#of new N
1
AdditionalInformation: � >
Q �
� �
Type of Construction: � �
(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete '
( )Other � ,�
�
Construction Cost:Primary Structure$ ti
D � a i���-o Addition:$ � �
Accessory Building:$ ° � �
80/ 3 �
Deed:Vol J 0'�} Pg � Certified Soil Test# 90-/Y� /9L-LY`��, z
tio ,�
CSM:Vol_1�Pg�_Lot#_ � Sanitary Permit# 9Z-/79 "
Plat Envelope Or: � �n
Condo Vol Pg Year Installed: n�
I\,)
"Loads and Flows": Vol Pg Owner When Installed: � �
o^
Previous office approvals/actions: �
Variance:# LUP:# SP:# CUP:# —
Inspection Report:# Change of Zone District:
�1����
3 4'7&
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���ft.wide fr.wide ft.wide ft.wide
_�ft.long ft.long ft.long ft.long
Floor area�sq.ft. sq.ft. sq.ft. sq.ft.
Hgkfromgiade /D•�topeak ft.hgt. ft.hgt. ft.hgt.
Stories � stories stories stories
#of bedrooms�
Lake/Po�d/Flowa e/River/Stream Name
w��rnCGd ��6 0 �
5�
1 �$` �
� �y� / .
6 L, � i
�2S
98'�, �G �
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P �.q, ,�- �.
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Fire Number and Name of Road g��.3� �C�t u �•
1. Enter lot dimensions and indicate north by arrow. Si a re of Own or uthorized A ent:
2. Indicate the location and size of the requested construction
Signature
activities. i—
Print me: J f1'mt�S �. �1l�/g�S
3. Also,indlCate tlle locatlon and dlStanCe to the Well, The a ve cedifes that the listed intormation and intentions are
true and wrrect,that all work shall be performed in compliance
septic tank and drainfield,wetland areas,lot lines, w�m me req���eme�a or me sawyer co�nry zoo��9 ordma�ce
and the laws and regulations of the State of Wisconsin,and if
Centerllne of the roaCl anCl watelbodles. acting as ownef(s)agent,has�he permission ot the owner(s)to
peAortn ihe work requested on this appliration. The above
personsls hereby give permission for access to the property for
onsiteinspeclion.
O�
Permit fee:$ 75
Total land area within 300'of the waterbody:(A) � O�a
Total impervious surface azea[includi g this project](B) .����
e
(B)/(A)x 100=%Used 1�• � d (Shall not exceed I S%[or 25%with a condirional use permit].)
Shoreline Vegetation Protection Area:Mitigation Required7 O Yes O No
,' )
June 29 2004 � �
Issue Date Signature of Issuing Agent
June 29, 2005 50%Rule: AverageRoadSetback:
Expiration Date
Office Comments:
SHORELAND PRESERVATION AGREEMENT
(Shoreline Veeetation Protection Area)
Land Use Permit No. � - / (To be entered by the Zoning OFfice) Index No. �_- �J / 7
WHEREAS, (list all owners) �✓AN5 ��'�+ I� ��2�.i ST , Tf�'mt'-5 � - E�?an�S
� 3^oA�► �, �. Ev��s �tus��s
owns real estate within Sawyer County that is subject to the Sawyer County Shoreland Regulations, and
WHEREAS, in order to secure a Land Use Permit.
� NOW, THEREFORE, the owner(s) hereby certifies that, as a condition of issue of said Land Use Permit, that
i the SHORELINE VEGETATION PROTECTION AREA on said real estate is intact to a minimum depth of
r" 35' landwazd from the ordinary high-water mazk of the waterbody.
a
' The owner(s) hereby agrees to comply with the shoreland vegetative protection area requirements of Section
� 4.410 SHORELAND VEGETATION PROTECTION AREA, Sawyer County Zoning Ordinance, in effect on
� the date that the land use permit is issued by the zoning office. The owner(s) further agrees to allow authorized
representatives of the Governmental Unit to enter onto the owner's property at the following description
� between the hours of 8:00 A.M. and 6:00 P.M. [Section 9.13(1) POWERS, Sawyer County Zoning Ordinance]
� to inspect the structure(s) or uses authorized by said Land Use Permit and to determine if the SHORELINE
j VEGETATION PROTECTION AREA exists and that it is being preserved. This authorization shali terminate
�l! on the date of expiration of the land use permit. However, the owner's obligation to maintain the SHORELINE
VEGETATION PROTECTION AREA in accordance with Section 4.410 SHORELAND VEGETATION
L� PROTECTION AIZEA, Sawyer County Zoning Ordinance remains in effect. Violation of this Agreement will
� authorize, in addition to other penalties and relief required under the Sawyer County Zoning Ordinance,
� injunctive relief, restoration of said real estate, the revocation of said Land Use Permit and the removal of all
T structures approved by the issue of said Land Use Permit and the revocation of any other uses approved by the
� issue of said Land Use Permit. All parties agree that this Agreement shall be filed with the Sawyer County
Zoning Office.
Legal Description of Property: � �oT � �� � I t-w .J �a /� � � k1
C�crm (�u �'El2- � O u 'L — 9 y D � 1 —5'-1 f I _
Dated this o� > day of .-.�u,V L= , L�s o '�
( er) (Owner)
( er) (Owner)
( er) (Owner)
This instrument was drafted by:
Sawyer County Zoning Office
�
TOWN OF BASS LAKE �
SEC . 21 T 40 N. R. 9 W.
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