020-103-00-3601-LUP-2004-096 � Application for Land Use Permit(*Non-shoreland*) o 0
County of Sawyer � �
PO Box 676 -Haywazd WI 54843
715/634-8288 � '
*Property that is not located within 300'of a creek,river or stream or within 1000'of a � t l�
flowage,lake or pond or does not have any of the above waterbodies located within s S fi�
the property's boundaries. ' cd � �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. �` �
`�v c}, ria 1Q y r. ;� PRINT-USE BLACK INK OR PENCIL j�
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7e��(�,I L �YNl��{��� �C� G�.
Owner Builder �' �
1.! R(ol D �.¢.�'r^ L.✓� �.
Mailing Address Mailing Address � �
O`STp��4 la 1, s4$�Z � �
City,State,Zip City,State,Zip � �
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Daytime Phone Daytime Phone �' ,
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Additional Information: Zone District: �'� �
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Lot Dimensions: �t. �
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Date lot was created: Acres: /� 33 0 � ',
Is there wetland near the proposed structure?If yes,how faz IV(� �
Building Land Use Floodptain:� j Yes (1�No `; �
New (�Filling �
O Addition O Dredging Driveway access off of a(Check one): �`D.,
O Alteration Tj�Grading O Private Rd (�-Town Rd o
( )Moving On ( ) ( )County Hwy ( )State Hwy N �
O O o S
r
Primary Structure Accessory Building Addition � °
( )Dwelling fj4.Gazage-attached/detached (y Deck W
( )Yeaz round (:�#of caz stalls ( )Porch �
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen
( )Mobile/manufactured ( )Other ( )Bedroom p �
( )Other primazy structure ( ) ( )Relocate/enlarge
� � ( ) ( )#of new �
AdditionalInformation: t` a
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Type of Construction:
(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete �
( )Other �
ro �Construction Cost:Primary Structure$ '� (t7�y��o �
:?
Accessory Building:$ Addition:$ x�
Deed:Vol �' Pg y'i Certified Soil Test# 99-�9� tl4 z
CSM:VoI Pg Lot# SanitaryPermit# 99-025 �, 7y
Plat Envelope Or: �;, �
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Condo Vol Pg Year Installed: �o
Aff of ex septic Vol Pg Owner When Installed: " �
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Previous office approvals/actions: w
Variance:# LUP:# ��1��Q� SP:# CUP:# �
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Inspection Report:# Change of Zone District: '�- y I I 3I�
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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. 1 c+-r - #3. �2 i #4.
Size ft. wide �LL wide �_ft. wide 8. wide .
fr. long �fr. long ��ft. long ft. long
Floor azea sq. ft. ~Ia v sq. ft. I9� sq. ft. sq. ft.
Hgt.from gade to peak ft. hgt. fr. hgt. ft. hgt.
Stories stories stories stories
# of bedrooms
Rear Lot Line
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Fire Number and Name of Road �n) �Z lo(�, c� (J 2 e�' � N �
1. Enter lot dimensions and indicate north by arrow. �9 t u� of Owner or tho�i d Agent:
2. Indicate the location and size of the requested construction <. ,
i a re
activities. f �.��,,,1 5 C�k �
Ptlnt Name: �Q(
3. A1s0, indicate the location and distance to the well, The above certifies t�ted information and intentans are
We and correct.,that all work shall be peAortned in compliance
SeptiC taI11C anCl ClTalnfleld, Wetland azeas, lot Ilnes anCl to Y.�le with ihe requiremen4 ot ihe Savryer Counry Zoning ONinance
and Ne laws and regulalions of the State of Wisconsin, and if
Centeilln0 Of tlle io8d. acting as owner(s)agent has the permission of ihe owner(s)to
perfonn the work 2quesled on Nis application. The a6ove
personsls hereby give permission for access to the property for
/�Q onsite inspection.
Permit fee: $
April 27 , 2004 G�t _
Issue Date Signature ofIs in gent
April 27 , 2005 50% Rule: AverageRoadSetback:
Expiration Date
Office Comments:
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