020-638-03-2302-LUP-2004-248 i
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Application for Land Use Permit (*Non-shoreland*) r � ,
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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 PERMTTS HAVE BEEN ISSUED. ,
PRINT—USE BLACK INK OR PENCIL _
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Owner Builder �'
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Mailmg Address A Mailing Address � � �j� � � �y �
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City, State, Zip City, State, Zip
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Daytime Phone Daytime Phone
Additional Information: Zone District: ��� ('�
Lot Dimensions:
Date lot was created: Acres: � �7 n
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Is there wetland near the proposed structure? If yes, how far �
Building Land Use Floactptain:( j �es (�No °
�New ( ) Filling �
O Addition O Dredging Driveway access off of a(Check one): �, _
( ) Alteration ( ) Grading ( ) Private Rd � Town Rd. o
O Moving On O O County Hwy O State Hwy N
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Primary Structure Accessory Building Addition � °
� Dwelling ( ) Garage-attached/detached ( ) Deck W
�f Year round ( ) # of car stalls ( ) Porch � �
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen
( ) Mobile/manufactured ( ) Other ( ) Bedroom � ' .-
( ) Other primary structure ( ) ( ) Relocate/enlarge A "
� � � � ( ) # ofnew ;
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AdditionalInformation: � �
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�e of Construction: �'
Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete �
( ) Other � y
Construction Cost: Primary Structure $ ���/ �. �
Accessory Building: $
Addition: $ � �1
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Deed: Vol '? 1 3 Pg ��� Certified Soil Test# _ � z
Lot# Sanit Permit#Q�?�CS ,P, ���� � ~ �
CSM: Vol Pg �' .�� � �
PlatEnvelope pr: ��r��-�i�S ����'��`� �
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Condo Vol Pg Year Installed: �
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Aff of ex septic Vol Pg Owner When Installed: `-'
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Previous office approvals/actions: ..
Variance: # LUP: # SP: # CUP: # �
Inspection Report: # Change of Zone District: ����t-�
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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 ft. long ft. long
Floor area � a� _ sq. ft. sq. ft. sq. ft. sq. ft.
Hgt. from g�rade � to peak ft. hgt. ft. hgt. ft. hgt.
Stories � stories stories stories
# of bedrooms �
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Rear Lot Line
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Fire Number and Name of Road � �� �a �� �-E-�-`�'� I��'�-`�-F'
1 . Enter lot dimensions and indicate north by arrow. $� ture of Owner o ut r ed Ag .
2. Indicate the location and size of the requested construction i
Si ure
activities.
Print Name:
3. Also, indicate the location and distance to the well, The above certifies that the listed information and intentions are
true and correct., that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines and to the with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
centerline of the road. aot��9 as ow�er�s� a9e�t, has the permission of the owner(s) to
perfortn the work requested on this application. The above
personsls hereby give permission for access to the propeRy for
���.� onsite inspection.
Permit fee: $ � � �
June 9 � 2004 �
Issue Date Signature of I uin gent
June 9 , 2005 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
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, _ t FOR ASSESSMENT USE ONLY � 4��
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