014-842-17-1103-LUP-2004-505 Application for Land Use Permit�*Non-shoreland*) o 0
County of Sawyer �
PO Box 676 -Haywazd WI 54843
715/634-8288 � �
*Properiy 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 ` 1
the property's boundaries. � �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. a
PRINT-USE BLACK INK OR PENCIL �
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�/LiAn/ �S/-IN�y �TON� �/L/AN �T�/`�� Q
Owner r Builder <
/��d�S /,r/ ��T�.e✓Oi✓ /�a• �AME ,"��� �
Mailing Address Mailing Address O
�A��A�.d, �vs .��8�-� �
City,State,Zip City,State,Zip h
7�y> �.��-.�3.��- �
Daytime Phone Daytime Phone �.
Additional Information: Zone District: /�Q,�.,� 11�
Lot Dimensions: ��'X��}' �
Date lot was created: — Acres: — ��• -1�' n �
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Is there wetland near the proposed structure?If yes,how faz /v4 � t�
Building Land Use Floodptain:� j Yes (�No :; �
(v�New ( )Filling � �
O Addition O Dredging Driveway access off of a(Check one): � ��
O Alteration O Grading O Private Rd O Town Rd. o Z
O Moving On (✓)'ONT%M�E/L.5 O County Hwy O State Hwy �, �
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Primary Structure Accessory Building Addition � °
( )Dwelling ( )Garage-attached/detached ( )Deck „"',
( )Yeaz round ( )#of car stalls ( )Porch =
( )Seasonal (v�Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room �
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen �
( )Mobile/manufactured ( )Other ( )Bedroom , �
O Other primary structure O O Relocate/enlazge s
� � ( ) ( )#of new �� �
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AdditionalInforxnation: J �
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Ty e of Conshuction: �J �
(✓�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete ,
( )Other ,ti ,�
Construction Cost:Primary Structure$ �`"' � �
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Accessory Building:$ �,���• Addition:$ � �
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Deed:Vol 5�Pg yy Certified Soil Test# ��-C�Rv °4 z
CSM:Vol Pg Lot# Sanitary Permit# 75-�5� � �
Plat Envelope Or: �
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Condo Vol Pg Yeaz Installed: �
Aff of ex septic V ol Pg Owner When Installed: " �
Previous office approvals/actions �f� �
Vaziance:# LUP:# 95- 159 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 /� ft. wide ft. wide ft. wide ft. wide
�ft. long ft. long fr. long fr. long
Floor azea o��� sq. ft. sq. ft. sq. ft. sq. ft.
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Hgt from gade � 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 l.3 ��$ W ��7�/C�on� /�
1. Enter lot dimensions and indicate north by arrow. Sig�u�e of Owpe�of Authorized Agent:
2. Indicate the location and size of the requested construction �j � ,d�f..�
SignaN2
activities. �j/LiA,N �T���
Print Name:
3. Also, indicate the location and distance to the well, The above ceNfies mat the listed intortna6on and inteNbns are
true and correct.,ihat all work shall be peAortned in compiiance
Sept1C tank and clTalnfielcl, wetland azeas, lot 11nes and to the with the requirements ot ihe Savryer County Zoning Ordinance
and the laws and regulations of ihe Shate of Wisconsin, and if
CCritCi11RC Of t110 70ad. acting as ovmer(s)agent has the pertnission of the owner(s)to
peAorm Me woAc requested on this apptiration. The above
personsls he2by give permission for access to Ne property for
7 � onsRe inspedion.
Permit fee: $
September 15 2004 - � —
Issue Date Signature of I s ing gent
September 15, 2005 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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