010-128-00-1600-LUP-2004-183 Application for Land Use Permit (*Non-shoreland*) o U - ' �
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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Owner � Builder ', c' �
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Ma'ling Add ess Mailing Address �
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City, State, Zip City, State, Zip �
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Daytime Phone Daytime Phone �r �
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Additional Information: Zone District: �"�_. �� �
Lot Dimensions: f�5 � �`� �=—
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Date lot was created: ;� -�� ��Ll Acres: �� �' o
Is there wetland near the proposed structure? If yes, how far /� �
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Building Land Use Floodplain:( j �es (jC) No �°
�� New ( )Filling �
Addition O Dredging Driveway access off of a(Check one): �,
O Alteration O Grading �) Private Rd O Town Rd. o
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy N �
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Primary Structure Accessory Building Addition � °
( ) Dwelling ( ) Garage-attached/detached ( ) Deck W
( ) Year round ( ) # of car stalls ( ) Porch �
O Seasonal � Storage Building O Enclosed �
( ) Frame built on site ( ) Screenhouse ( ) Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen �
( ) Mobile/manufactured ( ) Other ( ) Bedroom _
( ) Other primary structure ( ) ( ) Relocate/enlarge '
( � O O # ofnew
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AdditionalInformation: Q .� r
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Type of Construction: �
(� Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete
( ) Other
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Construction Cost: Primary Structure $ � �
Accessory Building: $ /��v��' Addition: $ �
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Deed: Vol �� � Pg�� Certified Soil Test# ��� �(�8 � �" Z
CSM: Vol ��( Pg �.� `? l�ot#� Sanitary Permit# ���} —(�� � 7�
Plat Envelope � �d� � Or: �;
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Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: `-' �
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Previous office approvals/actions:
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Variance: # LUP: # �Ca -��� SP: # CUP: # `�
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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 '
colu�}n. List each story, each addition, each alteration in a separate column.
#1 .�-1�i� � '- e'r-�c.�� #2. #3. #4. �
Sizc �3 ft. widc ft. widc 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 bedroo��_ - - -
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�� Rear Lot Line
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Fire Number and Name of Road �(�p���� ���Lt:�'�- 1.�c1�
1 . Enter lot dimensions and indicate north by arrow. Sig atur a, Owner or Authorized Agent:
2. Indicate the location and size of the requested construction
Signature
activities. �������,f
Print Name:
3. Also, indicate the location and distance to the well, The above certifies that the listed information and intentions are
true and correct., that alI work sha�i 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 �equested on this application. The above
persons/s hereby give permission for access to the property for
onsite inspection.
Permit fee: $ �(J�
May 14 2004 1 7�—
Issue Date Signature of Is uing ent
May 14 , 2 0 0 5 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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CERTIFIED SURVEY MAP
ALL OF LOTS 11, 12, 13, and 14 OF THE PLAT OF
"" '�f6 GREENWOOD HILLS. BEING A PART OF THE SW/NW
C0R OF SECTION 28, TOWNSHIP
[oNn roaa
r N89' 35' o7"E 41 NORTH, RANGE 9
c`,�, ;, WEST, TOWN OF
oec 9 1 172 35' r ",a HAYWARD, SAWYER
0e�� ; P P2 (172. 16) `fl �'o� 3 �OUNTY,
N �pPP `ti�'� LOT 17 o p�'= WISCONSIN
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