010-841-20-1301-LUP-2004-148 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 j�
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 B$EN ISSUED. r_
PRINT-USE BLACK INK OR PENCIL L"
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Owner Builder �' �
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Mailing Address Mailing Address �O
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City, t te,Zip City,State,Zip
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Daytime Phone Daytime Phone
AdditionalInformation: ZoneDistrict: r-�`'�
�,`,�c�,�CLJ ;} ��5-,����;�
Lot Dimensions:
Date lot was created: Acres: V�G9. i ry n
0
Is there wefland near the proposed structure?If yes,how faz G �
Building Land Use Floodplain-( j Yes O No �
( )New ( )Filling �
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd O Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy ti, �
� ) � ) o S
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Primary Structure Accessory Building Addition .�'o °
( )Dwelling ( )Garage-attached/detached ( )Deck W
( )Year round ( )#of caz stalls ( )Porch .=
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room �- �
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen � �_
( )Mobile/manufactured ( )Other ( )Bedroom � �
( )Other primary structure ( ) ( )Relocate/enlarge � '�
� � ( � ( )#of new tg C
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AdditionalInformation: i p
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Type of Construction: e I�
( )Frame ( )Log �Pole/metal ( )Block ( )Concrete ��
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( )Other ,tiy .�
Construction Cost:Primary Structure$ � '�
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Accessory Building:$ �` � Addition:$ x� �C
Deed:Vol�Pg� Certified Soil Test# °Q z
CSM:Vol Pg Lot# Sanitary Permit# o� �
Plat Envelope Or: N ��
Condo Vol Pg Year Installed: ' � �
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Aff of ex septic Vol Pg Owner When Installed:
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Previous office approvals/actions:
Variance:# LUP:# SP:# CUP:# �
Inspection Report:# Change of Zone District:
s/�1�`I
�113�
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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. ST�. !_�i.i`C;� #2. #3. #4.
Size 3U fr. wide ft. wide ft. wide ft. wide
yd ft. long ft. long ft. long fr. long
Floor area �3G'� sq. ft. sq. ft. sq. fr. sq. ft.
Hgt.from gade /� to pealc fr. hgt. fr. hgt. ft. hgt.
Stories � stories stories stories
# of bedrooms �
Rear Lot Line
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Fire Number and Name of Road / � / � �
1. Enter lot dimensions and indicate north by arrow. Si atuf ' d Agent:
2. Indicate the location and size of the requested construction '
5g al re
activities. /
PrintName: �K�v.� ���f+'0i�-1,'�
3. A1So, inC�iCate the IoCatlon and dlStanCe t0 tlle well, The above certifies at the listed intormation and intentions are
irue and correct., Nat all work shall be pedormed in compllance
septic tank and drainfield, wetland areas, lot lines and to the with ihe requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the Sfate of Wisconsin, and if
COriteLline of t}le Io2d. acting as owner(s)agent, has the permisslon o(the owner(s)to
peAortn the work reques�ed on ihis application. The above
personsls hereby give permission for access to the properry for
onsite inspection.
Permit fee: $ ��
r�y 5, 2004 - � � -
Issue Date Signature ofIss in gent
May 5, 2005 50% Rule: Average Road Setback: _
Expiration Date
Office Comments:
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