016-637-17-2401-LUP-2004-200 Application for Land Use Permit o o, �
County of Sawyer � �
PO Box 676 -Hayward WI 54843
715/634-8288 �r�
The undersigned hereby makes application for a Land Use Permit and agrees that all work � �
shall be done in compliance with the requirements of the Sawyer County Zoning Ordinance °
and the laws and regulations of the State of Wisconsin. `
NO CONSTRUCTION MAY BEGIN UNTIL ALL PERMITS HAVE BEEN ISSUED. �; �
PRINT-USE BLACK INK OR PENCIL ,'
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Owner Builder �
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Mailing Address Mailing Address �o� ��X 3 y S' �
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City,State,Zip City,State,Zip �
7,s-, 9�i3 - �-`i�' ,: 7/S-_ ;Z3% -i�3.17
Daytime Phone Daytime Phone
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Additional Information: Zone District_� ' �t
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Lot Size l3 3 9 � �3� � ���
Date lot was created ? Acres �/G 't
Is the property in a Shoreland District?(within 1000'of a lake or pond,within 300'of a river, �
creek or stream) If yes,how faz from the shoreline&water name: r
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Is there«etland near the proposed structure?If yes,how far N� �
Building Land Use c
(k)New ( )Filling � Floodplain:( )Yes (X)No # ;;
( )Addition ( )Dredging � �
( 1 Alteration O Grading Chippewa Flowage: O Yes (X)No Q �
( )Moving On ( ) � r
� � ( ) Driveway:( )State ( )County (yc)Town Rd. s
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Primary Structure Accessory Building Addition J
(j�)Dwelling ( )Garage-attached/detached ( )Deck `
(k)Yeaz round ( )#of car stalls ( )Porch ��
( )Seasonal ( )Storage Building ( )Enclosed � I��
O Frame built on site O Screenhouse O Living room p�
(x)Modulaz/manufactured ( )Greenhouse ( )Kitchen � �
( )Mobile/manufactured ( )Other ( )Bedroom �
( )Other primary structure ( ) ( )RelocateJenlazge -
� � ( ) ( )#ofnew p
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0
Additional Information: �
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Type of Co�struction �
(}c)Frame � ( )Log ( )Pole/metal ( )Block ( )Concrete �
( )Other ' �
Construction Cost:Primary Structure$ i,Z�,e �_�
Accessory Building:$ Addition:$ � z
7y
Vol 3�5 Pg ��4 of Deed Certified Soil Test# �0 - � • �
CSM Vol Pg Lot# Sanitary Permit# �f•'� - i�i'7 /1�--/�{�
Plat Envelope Or: � �
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Condo Vol Pg Yeaz Installed�-/N-/ �1 9�
Aff of ex septic Vol Pg Owner When Installed:
Gard Gazebo Vol Pg
Ins ection Date: �a\�
Previous Variance: L�'� p
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. �[j� #2. #3. #4.
Size_�ft.wide �// ft.wide fr.wide ft.wide
�C ft.long 6C ft.long ft.long ft.long �
Floor area /F611 sq.ft. /fb�Y sq.ft. sq.ft. sq.ft.
Hgt.from gade ,����g�$?�ft.hgt. �ra r�g'A�; ft.hgt. ft.hgt.
c��� 5-,��y.=,�,y� �_stories stories stories •
#-a€i�edreems�_ 3 d c d,�o-",re s
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� Lot Line or Lake/River name: -
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Fire Number and Name of Road 9�2�/ v✓ Si�i /rf,� �f''i)
1.Fill in lot dimensions and indicate north by arrow. Signature of Owner or Authorized Agent:
2.Indicate location and size of existing and new structures. ����� ��
3.Indicate location ofwell,septic tank,drainfield. �I�yu� ��`✓�:C�
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4.Indicate distance to existing sh�uctures,lot lines,septic system.
5.Indicate distance to the ordinazy high-water mazk of any lake, �.,r oc F�-''�`r .
pond,river,stream,creek,and name the body of water. a�nc Name: D.4v,,� �g���L Cy
The above certfles Nat the listed information and intenGons are
6.Indicate any grading or clearing in excess of the construction site. a�ss lo me property foonsit rsnspecUoneby give permission for
7,Indicdte distance to any wetland.
Pemut Fee: ��Z S:�' :
May 19, 2004 " � �
Issue Date Signature of Issu g nt
May 19, 2005
Expiration Date
Office Comments:
Inspection Date: 50%Rule Applies: Avg.Setback: Within Reservation boundaries:
Restrictions and other information:
TC�WN OF MEAQC�`
SEC . 17 TWP. 3 � N . �
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