014-842-15-4411-LUP-2004-230 Application for Land Use Permit(*Non-shoreland*) o o ���
County of Sawyer �
PO Box 676 -Hayward WI 54843 O
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. ,J '
PRINT-USE BLACK INK OR PENCIL �`
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Owner \ Builder �—j �'
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Mailing Address /r�(,,7 Mailing Address O
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City,State, ip City,State,Z�p
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Daytime Phone Dayhme Phone .�
Additional Information: Zone District: /��`,'7�
Lot Dimensions: �
Date lot was created: Acres: � �S 3 n »
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Is there wetland neaz the proposed structure?If yes,how faz I� � � ��
Bu ding Land Use Floodptain:� )Yes (�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 �, �
� ) � ) o �
Primary Structure Accessory Building Addition �
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( )Dwelling Q�iazage-attached/detached ( )Deck W �
( )Yeaz round ( )#of car stalls ( )Porch =
( )Seasonal ( )Storage Building ( )Enclosed `D
�
O Frame built on site O Screenhouse O Living room a � �
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen — (� 2�
( )Mobile/manufactured ( )Other ( )Bedroom -f- �
Other rimar structure Relocate/enlar e � `^
� � � P � ( ) ( )#of new g -� �n �„
� �1 ��
AdditionalInformation: ' A
�tl �
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Typ f Construction: r--
Frame ( )Log ( )Pole/metal ( )Block ( )Concrete �-
�
( )Other ro ,�
Construction Cost:Primary Structure$ � �
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Accessory Building:$�r/S�G Addition:$ sa "�
r � �:�
Deed:Vol �'"�� Pg:�`1.✓ Certified Soil Test# Od-a�7 °Q z
CSM:Vol_�' _Pg ��;"'7 Lot# �'J Sanitary Permit# oa-d51 0, %�
P1atEnvelope ��yy� Or: �, k�
Condo Vol Pg Year Installed: o I�
Aff of ex septic Vol Pg Owner When Installed: "
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Previous office approvals/actions:
Vaziance:# LUP:# oa-3�i SP:# CUP:#
Inspection Report:# Change of Zone District: ��'1�G�-�
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i�ssy
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.
Size_ ft. wide ft. wide ft. wide ft. wide
ft. long ft. long ft, long ft. long
Floor area 5 74— sq. ft.
Hgt. from grade to peak
Stories f
# of bedrooms Imo`
Fire Number and Name of Road
sq. ft.
ft. hgt.
stories
1. Enter lot dimensions and indicate north by arrow.
2. Indicate the location and size of the requested construction
activities.
3. Also, indicate the location and distance to the well,
septic tank and drainfield, wetland areas, lot lines and to the
centerline of the road.
sq. ft. sq. ft.
ft. hgt. ft. hgt.
stories stories
Signa re of Owner Authorized Agent:
Signatu�j
PrintName:"
The above cerfifiEs that the listed infarrnation and intention are
true and correct., that all work shall be performed in compliance
with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
acting as owner(s) agent, has the permission of the owner(s) to
perform the work requested on this application. The above
personsls hereby give permission for access to the property for
onsite inspection.
Permit fee: $ I00
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GRAPHIC SCALE TAX ASSESSMENT PURPOSE
�oo o zao +oo aoo ieoo Informat�on contained on this i
advisory. Map accuraty is limit
quality of the public records fi
was prepared. It is not intendc
( IN FEET ) substitute for an occurate fielc
1 inch = 400 ft.
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