024-741-19-5303-LUP-2004-489 . �
' � Application for Land Use Permit(*Non-shoreland*) o o.
- County of Sawyer �
PO Box 676 -Haywazd WI 54843s�� f ji=^�;;;;;; .�;::jp;;°�F'�,�(-� �
715/634-8288 f
*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. � 1
PRINT-USE BLACK INK OR PENCIL n
� �
�IC.�iae,I `q- j�oGL,j' SN�� M�G�t��� Nl�����F� a �
Owner / Builder '<'
��0?3 VA��eS� �i�r�/'v�h ���? �/erl�� Cc,rvi �a-p �' �
Mailing Address Mailing Address �
M�do� ���y�.� �n�.ssr�A /"1-e�ldofi�t �c��hts,�'l,v.ssl/� :; �
City,State,Zip City,State,Zip �
�12� �41r4-- �oa� l rJ_ 8��_ aoaf r
Daytime Phone Daytime Phone
a
Additional Information: Zone District:!���� �
Lot Dimensions 2rrT �i}q/
Date lot was created: (`��� Acres: - Sd ��-- � �
Is there wetland near the proposed structure?If yes,how faz N U � �
Building Land Use Floodptain:( j Yes (�No �
( )New ( )Filling �,
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd Q�Town Rd. o
O Moving On O O County Hwy O State Hwy i G�
�j G� ( ) g �
r
Primary Structure Accessory Building Addition � °
( )Dwelling (�Gazage-attached/detached ( )Deck w ��J
O Year round (3)#of car stalls O Porch �
( )Seasonal ( )Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room o
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen �
( )Mobile/manufactured ( )Other ( )Bedroom -C �
( )Other primary structure � ) ( )#of new�enlazge �
O � � �
AdditionalInformation: ►� A
� �
ov �
Type of Construction: �� �
4Cj Frame ( )Log ( )Pole/metal ( )Block ( )Concrete
( )Other .b .�
Construction Cost:Primary Structure$� � �
� �
Accessory Building:$ 3o�oa Addition:$ � �
r� azySo7 `°
Deed:Vol Pg Certified Soil Test# 75-3!9 a' z
CSM:VoI � Pg/���rcyLot# �- SanitaryPermit# 'J5-20lo b� �
Plat Envelope �3�� Or: N `�l
Condo Vol Pg Year Installed: � I�
Aff of ex septic Vol Pg Owner When Installed:
�
Previous office approvals/actions: �
Vaziance:# LUP:# Ol-�40 SP:# CUP:#
Inspection Report:# Change of Zone District: �,�.�
$���a,�
;�553�
Describc 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.
#L ��q.r�c o c- #2. #3. #4.
Size�ft. wide ft. wide ft. wide ft. wide
'drC.� � r
� 0 ft. long ft. long ft. long ft. long
Floor area�'sq. ft. sq. ft. sq. ft. sq. fr.
Hgt.from giade �S' to peak ft. hgt. ft. hgt. ft. hgt.
Stories � sYories stories stories
# of bedrooms U
Rear Lot Line
S�� K7t�iC-Lt!(� �Yawlh�
Fire Number and Name of Road /0 9& 3 �/ l�E`�/l1 G L� %�[)/�-D
1. Enter lot dimensions and indicate north by arrow. Sign Y o,f10w a r�r� ed Agent:
2. Indicate the location and size of the requested construction � .l� _
Signature
activities.
Pnnt Name:
3. f�iSO, 1rid1C8Y0 t110 IOCaYIOri 211C�d1St1I1C8 t0 t110 W011, The above certifies that Ihe listed information and Intentions are
irue and covect,that all work shall be performetl in compliance
Sept1C t3T11C 3T1C�dTalnfteld, wetland 2leas, lot lines anC�to tl'le with the requiremenfs ot the Sawyer Counry Zoning Ordinance
and the laws and regulations of the St21e of Wisconsin, and if
Centelllne of�le Io2d. acting as owneV(s)ageN, has the permisslon o(the ownar(s)to
pedortn the work reques�ed on this applicalion. The above
personsls hereby give permission for aceess to the property for
onsite inspection.
Permit fee: $ lUv
September 8, 2004 1�,������ ~ 6��?��
Issue Date Signature of Issuing Agent
September 8, 2005 a
50/o Rule: Average Road Setback: _
Expiration Date
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