010-941-21-1202-LUP-2004-239 Application for Land Use Permit (*Non-shoreland*) o o .
County of Sawyer � � �t,
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. r 1
PRINT-USE BLACK INK OR PENCIL �
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Owner Builder c.
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Mailing Address Mailing Address �
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City, tate, Zip City, State, Zip
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Daytime Phone Daytime Phone
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Additional Information: Zone District: ��� �
Lot Dimensions: •S/Lp� ,( /!�'O
Date lot was created: /�J'�3 Acres: �� o ' �
Is there wetland near the proposed structure? If yes, how far^�/v � �
Building Land Use Floadptain:( j �es (�'No ° r
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(7�New ( ) Filling � �
O Addition O Dredging Driveway access off of a(Check one): �,
( ) Alteration ( ) Grading ( ) Private Rd ( ) Town Rd. o
O Moving On O O County Hwy O State Hwy N
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Primary Structure Accessory Building Addition � °
( ) Dwelling � Garage-attached/detached ( ) Deck W
( ) Year round �) # of car stalls ( ) Porch �
( ) Seasonal ( ) Storage Building ( ) Enclosed �
( ) Frame built on site ( ) Screenhouse ( ) Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen :�
( ) Mobile/manufactured ( ) Other ( ) Bedroom � �
( ) Other primary structure ( ) ( ) Relocate/enlarge .�,� �'
� � ( � O # ofnew �-
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AdditionalInformation: �`' �
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Type of Construction: `�
� Fra�me ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete � �
( ) Other y
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Construction Cost: Primary Structure $ /O f�0 �
Accessory Building: $ Addition: $ ^ �
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Deed: Vol�,�Pg �l� Certified Soil Test# "� z
CSM: Vol Pg Lot# Sanitary Permit# r7,,,�j — C��/ � �
Plat Envelope Or: N ,�
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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: �'
SP: # CUP: # �
Variance: # LUP: # `��-'�/.� Ib�
Inspection Report: # Change of Zone District: �0�
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Describe the construction using these columns. List the dimensions of each structure in a separate
colum List each story, each addition, each alteration in a separate column. •
#1.��� #2. #3. #4.
Size '� ft. wide fr. wide ft. wide ft. wide
�2�' 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�_
Rear Lot Line
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Fire Number and Name of Road /u„s'-�'-' �^._ •'� �a a
L Enter lot dimensions and indicate north by arrow. Signat or Au ize ent:
2. Indicate the location and size of the requested constnzction .`
/� �gnaNie
activities. ��/�
PrintName�B G�f.o� GC /�IR'f�r✓
3. Also, indlCate tlle lOCatlon and QiSt3TICe to the well, The above ceRifes that Me listed information and intentions are
hue and correct.,ihat all work shall be pedormed in compllance
se tic tank and drainfield, wetland areas, lot lines and to the with the requiremenGs of the Sawyer County Zoning Ordinance
p and Ne laws and regulatlons of the State of Wiscronsin, and if
CORtCTI1RC Of t110 IOad. acting as owner(s)agenL has the permission of the owner(s)to
perfortn lhe work requested on this application. The above
personsls here6y give pertnission for access to the property for
onsite inspection.
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Permit fee: $ /L�C� "
June 7 , 2004 '
Issue Date Signature of Issuin Ag
June 7 , 2005 50% Rule: Average Road Setback: _
Expiration Date
Office Comments:
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