010-841-34-1101-LUP-2004-499 Application for Land Use Permit(*Non-shoreland*)
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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 1
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Owner Builder �
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Mailing Address Mailing Address O �
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City,State,Zip City,State,Zip
Daytime Phone Daytime Phone
Additional Information: Zone District: �}-�
Lot Dimensions:���� � :r-�� _
Date lot was created: Acres: o
Is there wetland near the proposed stnxcture?If yes,how far �
Building Land Use Floodptain:� j Yes O No :R
(�,)New ( )Filling '�
O Addition O Dredging Driveway access off of a(Check one): `D
00
O Alteration O Gxading O Private Rd O Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy N �
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Primary Structure Accessory Building Addition � °
( )Dwelling ( )Gazage-attached/detached ( )Deck W
( )Year round ( )#of car 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 �
Additional Information: p
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Type of Constnxction:
( )Frame ( )Log ( )Pole/metal ( )Biock ( )Concxete
( )Other y
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Construction Cost:Primary Structure$ � �
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Accessory Building:$ `f� ��r Addition:$ � _
st 3 z39S�� `D
Deed:Vol Pg Certified Soil Test# °Q
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CSM:Vol :Z5 Pg i`17 Lot# Sanitary Permit# o� 7'
�7-ry Or: N
Plat Envelope c2
CondoVol Pg .= ' YearInstalled: �c-tt�t' �b �Q�DO o
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Aff of ex septic Vol Pg Owner When Installed:
Previous office approvals/actions:
Variance:# LUP:# SP:# CUP:#
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 ;
column. List each story, each addition, each alteration in a separate column.
#1. #2. #3. #4. .
Size =' f: fr. wide ft. wide ft. wide ft. wide
G , R. long fr. long ft. long ft. long
Floor azea�_ sq. ft. sq. fr. sq. ft. sq. fr.
Hgt.from gacie�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 � ��:�I I 1 l e N�i �-�
1. Enter lot dimensions and indicate north by arrow. ignat of Own r Auth ized Agent:
2. Indicate the location and size o£the requested construction � 1�n ���
Signature p
activities. pdntName�, �,�,�{S o N fle�L�� �'
3. Also, 1ndiCate the loCatlon and dlstance to the well, The above cerlifes that the listed information and intentions are
true and corred., ihat all work shall be performed in compliance
septic tank and drainfield, wetland azeas, lot lines and to the with the requiremenGs of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wiscronsin, and if
centerline of the road. acting as owner(s)agent, has me permission ot the owner(s)to
peAortn the work requested on this applicalion. The above
personsls hereby give permission for access to ihe property for
onsite inspection.
Permit fee: $ af?(7 . n ��
September 14, 2004 �����1,� ��,_�ID� ��,,
Issue Date Signature of Is �ng gent —�
September 14, 2005
50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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PAULA CHISSER
� /�D SAWYER COUNTY, WI
G REGISTER OF DEEDS
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