010-941-16-3404-LUP-2004-179 Application for Land Use Permit (*Non-shoreland*) o o ! L
County of Sawyer � �
PO Box 676 - Hayward 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 �
the property's boundaries. �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT-USE BLACK INK OR PENCIL '
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�AQ�/Ar�� vA�EssA �-�D�Rr- �'EV E �nl L n,:��. �
Owner Builder c; �
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16/6�! �n1 I�oo�u�� �h��s �Q��rE l bl�6 v�1 �� C.��� �
M la ii ri Address Mailing Address O �
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A �w�� w=- 5�8�3 T�w�-�� W'L S�3 c„ �
City, tate, Zip City tate, Zip � �
�7�5� 63�-8So3 (� �7�s� 63�-37BqCW "1(S 6 �(- RS$ �
Da�yt'ime Phone Daytime hone � C�
Additional Information: Zone District: �- � ,,,,
��I when i►1�� Lot Dimensions: a30` X 3gb� N �
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Date lot was created: �P-�0'�� Acres: o �
Is there wetland near the proposed structure? If yes, how far /J f} � �
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Building Land Use Floodptain:( j Yes (�No `� t�
�New ( ) Filling � �
� �O Addition O Dredging Driveway access off of a(Check one): �
( ) Alteration ( ) Grading ( ) Private Rd (� Town Rd. o
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy ,; c
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Primary Structure Accessory Building Addition � °
( ) Dwelling � Garage-�Q�/detached ( ) Deck W
( ) Year round (al # of car stalls ( ) Porch �
( ) Seasonal ( ) Storage Building ( ) Enclosed �
( ) Frame built on site ( ) Screenhouse ( ) Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen Q '�
( ) Mobile/manufactured ( ) Other ( ) Bedroom -_
( ) Other primary structure ( ) ( ) Relocate/enlarge � '
� � O O # ofnew � �
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AdditionalInformation: .� �
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Type of Construction: �
� Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete b�
( ) Other y
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Construction Cost: Primary Structure $ � �
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Accessory Building: $^/�000_0 o Addition: $ � --�
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Deed: Vol��-�Pg ��[� Certified Soil Test# 9$� 13$ $S,?5� � z
CSM: Vol_�_Pg a�� Lot#_ ►'" Sanitary Permit# Q$-/b� 9$-l7a � �
Plat Envelope Or: �;
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: � �
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\_Previous office approvals/actions: �
� LUP: # !$, 3� SP: # CUP: #
Report: # Change of Zone District: I �I Ib`�
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I� (50
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 . �AR�C� #2. #3. #4.
Size_� ft. wide ft. wide ft. wide ft. wide
d2 g ft. long ft. long ft. long ft. long
Floor area 702$ 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 -�'
/
Rear Lot Line
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$ ! 1
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Fire Number and Name of Road � f 00 � � R �
1 . Enter lot dimensions and indicate north by arrow. Signatur of n r uthorized Agent:
2. Indicate the location and size of the requested construction _
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activities. GAR�/ ��F�.D�4/Z-i f
Print Nam
3. Also, indicate the location and distance to the well, The above certifies that the isted information and intentions are
true and correct., that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines and to the 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. acting as owner(s) agent, has the permission of the owner(s) to
perform the work requested on this application. The above
persons/s hereby give permission for access to the property for
onsite inspection.
Permit fee: $ /��8�
May 12 , 2004 ` — 7�
Issue Date Signature of Is 'n gent
May 12 , 2 0 0 5 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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CERTlFIED SURVEY MAP $94-1"
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