010-941-14-4402-LUP-2004-102 Application for Land Use Permit(*Shoreland*) o � •
County of Sawyer N � __
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 boundazies. �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT-USE BLACK INK OR PENCIL 1
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Owner Builder �/' p�-
z�� � < � c�� ��7�,1s.' a5—�.�c� � � �
//i'i��1lc��a � � l�
Mailin A ess_ � Mailing Address �
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[�/�t����.�) �� l.�Z���/�,,���' J���� �
C' ,State,Zip ' City,State,� ipZ� '
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Daytime Phone Daytime Phone
Additional Information: Zone District: R`�
�l4� L �✓ t';c��u�' � ,
LoY Dimensions: -<— 2c'o J� .3 e-c
Date lot was created: Acres: �,�3 �
Is there wetland near the proposed structwe?If yes,how far ,r/�% o �_
Building Land Use Floodplain:O Yes O No �
(�New ( )Filling Chippewa Flowage:( )Yes (Xj No �o _
O Addition O Dredging Driveway access off of a(Check one): � ^
( )Alteration ( )Grading ( )Private Rd (}C)Town Rd. � �1
( )Moving On ( ) ( )County Hwy ( )State Hwy � �
� ) � ) N �
� r
Primazy Structure Accessory Building Addition o 0
O Dwelling f,i�1 Garage-attache deta� O Deck �
( )Yeaz round (�)#of caz stalls ( )Porch �» ��.
( )Seasonal (�Storage Building ( )Enclosed =
O Frame built on site O Screenhouse O Living room c� �.S
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen �
ther Bedroom � /
( )Mobile/manufactured ( )O ( )
( )Other primary structure ( ) ( )Relocate/enlazge "~
� � ( ) ( )#of new �
r
Additional Information: �;
F �j
N
� �
Type of Construction: 3 �
(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete '�
( )Other �'
�
Construction Cost:Primary Structure$ ����: - �� �
Accessory Building:$ � Addition:$ ^ �
0
:°
'.�`� Certified Soil Test# �
Deed:Vol �2-�Pg�D� � z
CSM:Vol f� Pg�Lot#�_ Sanitary Permit# "' %`�
Plat Envelope �r� � �,
Condo Vol Pg Yeaz Installed: n� �
v, �
"Loads and Flows": Vol Pg Owner When Installed: �
ci
Previous office approvals/actions:
Variance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District: �"
.������
i�:o�� �
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.
#2.
#3.
#4.
Size ft. wide
ft. wide
ft. wide
ft. wide
- &,)_ 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 e
f
17
Fire Number and Name c
1. Enter lot dimensions ana
2. Indicate the location and
activities.
Lai Line or Lake/River name:
C(r"' LAJ
Road /D 1:57111 3
of the requested construction
3. Also, indicate the location and distance to the well,
septic tank and drainfield, wetland areas, lot lines,
centerline of the road and waterbodies.
Permit fee: $�
uiyiipwic // �
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.
Total land area within 300' of the waterbody: (A)
SHORELAND PRESERVATION AGREEMENT
(Shorelinc Veeetation Protection Area)
Land Use Permit No.�y-/pv� (To be entered by the Zoning Office) Index No. �-/oa
WHEREAS,(list all owners)��'l�>�,;���,�ftrr _
����i�e (��i.�'for
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
35'landwazd from the ordinary high-water mazk of the waterbody.
The owner(s)hereby agrees to comply with the shoreland vegetative protecrion 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
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
PROTECTION AREA,Sawyer County Zoning Ordinance remains in effect.Violation of tlus Agreement will
authorize, in addition to other penalties and relief required under the Sawyer County Zoning Ordinance,
injunetive 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.
LegalDescriptionofProperty: Part of theSE SE Section 14, T 41 N, R9 W. known as
1ot 5 of CSM vo1 14 pg 72. in Sawyer County, Town of Hayward, WI
010-941-14-4402
Dated this_��day of ��,/ z-��'`7�
(Owner) (Owner)
�x.'�u,�e, //�/ �C�.�.�1� —
(Owner)'�J - (Owner)
��� —
(Owner) (Owner)
This instrument was drafted by:
Sawyer County Zoning Office
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