004-839-08-5103-LUP-2004-588 ;---"
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Application for Land Use Permit (*Shoreland*) o 0
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 '� �
the property's boundaries.
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUEA f _ �
PRINT-USE BLACK INK OR PENCIL �,
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Owner Builder Q-:
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Mailing Address Mailing Address � �
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City, State, Zip City, State, Zip �
,�<'7.S i - `7.3.3 � �� �SA� �
Daytime Phone Daytime Phone �°.; -
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Additional Information: j��c /�'��-��- Zone District: i���� ��-,
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Lot Dimensions:��_% �= � �
Date lot was created: Acres: /;�� !.?7
Is there wetland near the proposed structure? If yes, how far i:'/' o �
Building Land Use Floodplain: ( ) Yes �No �
(�New ( ) Filling Chippewa Flowage: ( ) Yes (���) No �
O Addition O Dredging Driveway access off of a(Check one): �
( ) Alteration ( ) Grading ( ) Private Rd �?jTown Rd. �
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy °�'
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Primary Structure Accessory Building Addition o °
( ) Dwelling ( ) Garage-attached/detached ( ) Deck �
( ) Year round ( ) # of car stalls ( ) Porch W `
( ) Seasonal �} Storage Building ( ) Enclosed �
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( ) Frame built on site ( ) Screenhouse ( ) Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen �
( ) Mobile/manufactured ( ) Other ( ) Bedroom
( ) Other primary structure ( ) ( ) Relocate/enlarge � �
� � O O # ofnew �
Additional Information: �
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Type of Construction:
( )Frame ( ) Log �Pole/metal ( ) Block ( ) Concrete �
( ) Other y
Construction Cost: Primary Structure $ ,.d �
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Accessory Building: $ �p�d Addition: $ �
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Deed: Vol__]��__Pg y(o� Certified Soil Test# �'�f --�'-`-���� � z
CSM: Vol Pg Lot# Sanitary Permit# `;f�/- ` =� � �" �
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Plat Envelope Or: � �\.
Condo Vol Pg Year Installed:�9,�=?`� N
"Loads and Flows": Vol Pg Owner When Installed: r? �
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Previous office approvals/actions:
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Variance: # LUP:# SP: # CUP: #
Inspection Report: # Change of Zone District: � `'
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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. l��fc �l�d #2. #3. #4.
Size �ta ft. wide ft. wide ft. wide ft. wide
L/� ft. long ft. long ft. long ft. long
Floor area /:� �'/� sq. ft. sq. ft. sq. ft. sq. ft.
�� Hgt from grade `�� • to peak ft. hgt. ft. hgt. ft. hgt.
Stories � stories stories stories
#of bedrooms J �. . �
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Lake/Pond/Flowa e/River/Stream Name
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Fire Number and Name of Road ��.; �/�i''J � �``� ' ,
1. Enter lot dimensions and indicate north by arrow. Signature of�Owner¢r Authorized Agent:
2. Indicate the location and size of the requested construction � -l.� '��---�
Signature
activities. �' �
PrintName: / � ' �• ����'��'G'
3. Also, indicate the location and distance to the well, The above certifies that the listed nl formation and intentions are
true and correct.,that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines, with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
centerline of the road and waterbodies. aa��9 as ow�er�s�a9e�t, 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: $
Total land area within 300' of the waterbody: (A)_3TG��D ��. �f-
Total impervious surface area [including this project] (B) ��i<' _' =
(B)/ (A) x 100 = %Used l''�� (Shall not exceed 15%[or 25`% with a conditional use permit].j
Shoreline Vegetation Protection Area: Mitigation Required? O Yes o
October 15 2004 -' � 7-�
Issue Date Signature of Is ui A ent
October 15, 2005 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
SHORELAND PRESERVATION AGREEMENT
(Shoreline VeQetation Protection Area)
Land Use Permit No. v7-588 (To be entered by the Zoning Office) Index No. vy -�
WHEREAS,(list ail owners) �hr�"'— �� �/y7/t o
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
" the SHORELINE VEGETATION PROTECTION AREA on said real estate is intact to a minimum depth of
,S 35'landwazd from the ordinary high-water mazk of the waterbody.
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� The owner(s)hereby agrees to comply with the shoreland vegetative protection azea 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]
pto inspect the structure(s)or uses authorized by said Land Use Permit and to determine if the SHORELINE
� VEGETATION PROTECTION AREA exists and that it is being preserved.This authorization shall terminate
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
ap PROTECTION t1REA, Sawyer County Zoning Ordinance remains in effect.Violation of this Agreement will
QO 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
� 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.
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Legal D/escription of Property: ,l°',.t.�f e� G�i� �o��2 J � �ti�� ' j G"^'s,s-G �;' -
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Dated this .� ��� day of (�ci. ��`�
�w/�-.-.- -
(Owner) (Owner)
(Owner) (Ownex)
(Owner) (Owner) �
This instrument was drafted by:
Sawyer County Zoning Office
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