002-940-08-2101-LUP-2004-398 Application for Land Use Permit(*Non-shoreland*) o o , -�
County of Sawyer �, � �
PO Box 676 -Haywazd 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 U
the property's boundazies. � �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. ��
/�/� � PRINT-USE BLACK INK OR PENCIL �6
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o. �Owner Builder g
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Mailing Address Mailing Address O �
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City,State,Zip City,State,Zip n
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Daytime Phone Daytime Phone
Additional Information: Zone District: p-1
Lot Dimensions: � .,p
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Date lot was created: Z-Z(„-�Z Acres: 5.5Z-. o R.
Is there wetland near the proposed structure?If yes,how faz �
Building Land Use Floodptainrf )Yes Q�No :; i
�
(X)New ( )Filling
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd (X1 Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy „`'', �
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Primary Structure Accessory Building Addition � °
���Dwelling (:'�Garage-attached/detached (XI Deck w
� #of caz stalls��„��?��._? (�Porch '�
��Year cound f�") �
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room � �
�')Modular/manufactured ( )Greenhouse ( )Kitchen
( )Mobile/manufactured ( )Other ( )Bedroom � �
( )Other primary structure ( ) ( )Relocate/enlarge ,
� � � � ( )#of new 'a �
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AdditionalInformation: � A
y
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N �
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Type of Construction: � �
�O Frame ( )Log ( )Pole/metal ( )Block ( )Concrete �
( )Other .d -� �
` �' � !�
Construction Cost:Prnnary Structure$ �
Accessory Building:$ �, Addition:$ � � �
� 3/�r!%(c• �
Deed:Vol Pg Certified Soil Test# �^U ��/y °Q 'z C/)
Lot# Sanitary Permit# e��_��— o� � �
CSM:Vol ;�i Pg �`74. _�— .
Ylat�.nveiope �r' N I
Condo Vol Pg Year Installed: �' �
0
Aff of ex septic Vol Pg Owner When Installed:
�
s
Previous office approvals/actions: �
Variance:#
LUP:# SP:# CUP:#
Inspection Report:#_�
Change of Zone District: �\a\ba�
�F�
�q15
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. Tic IIL M Cam- #2. G ac1e. #3. #4.
Size 2 e) ft. wide a?) ft. wide 1 O ft. wide ft. wide
�{ ft. long 2 ft. long _.) ft. long ft. long
Floor area 1� sq. ft. - �It� sq. ft.
Hgt. from grade to peak ft. hgt.
Stories 1 stories
# of bedrooms 3
Lot
1 a� sq. ft. sq. ft.
ft. hgt. ft. hgt.
l stories stories
Fire Number and Name of Road % P49 m
1. Enter lot dimensions and indicate north by arrow.
2. Indicate the location and size of the requested construction
activities.
3. Also, indicate the location and distance to the well,
septic tank and drainfield, wetland areas, lot lines and to the
centerline of the road.
Sig to of Ow er or orized Agent:
signat re
Print Name:
The above certifies that the listed information and intentions are
true and correct„ that all work shall be performed in compliance
with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
acting as owner'(s) agent, has the permission of the owner(s) to
perform the work requested on this application. The above
personsls hereby give permission for access to the property for
onsite inspection.
Permit fee: $
/
, �
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7 1 5-6343 43$ N89'20'41V 1551.83' —'�'400.70' '—'J � �
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O� OWNER:
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