026-939-34-4101-LUP-2004-422 , �f,�
Application for Land Use Permit (*Non-shoreland*) o, o -
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 �
}�j� P�T the property's boundaries. �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT-USE BLACK INK OR PENCIL
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Owner Builder �;
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Mailing Addr ss Mailing Address ` O
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City, State, Zip City, State, Zi ��
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Daytime Phone Daytime Phone �
Additional Information: Zone District: � —'� �'
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Lot Dimensions:
Date lot was created: Acres: Z D ,D n
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Is there wetland near the proposed structure? If yes, how far �
Building Land Use Floodptain:� j Yes OC�No ` �
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�)New ( ) Filling � N
( } Addition O Dredging Driveway access off of a(Check one): �, �
( ) Alteration ( ) Grading (x) Private Rd ( ) Town Rd. o
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy �,
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Primary Structure Accessory Building Addition � °
( ) Dwelling ( ) Garage-attached/detached ( ) Deck W �
( ) Year round ( ) # of car stalls ( ) Porch � �
O Seasonal Q� Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen � 1��
( ) Mobile/manufactured ( ) Other ( ) Bedroom .� .-
( ) Other primary structure ( ) ( ) Relocate/enlarge � �
� � ( � ( ) # ofnew ��
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Additional information: 1 �
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Type of Construction:
( ) Frame ( ) Log �Pole/metal ( ) Block ( ) Concrete �
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( ) Other ,.b y
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Construction Cost: Primary Structure $ �6� �=r— �
�Accessory Building: $ .� 'o ���c% Addition: $ � G1
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Deed: Vol 7�Pg ��` Certified Soil Test# �" z
CSM: Vol Pg Lot# Sanitary Permit# a, �
Plat Envelope �r� N
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Condo Vol Pg Year Installed: dj�7�.�� ,�
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: �I(�I
6 �
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
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�� ft. long ft. long ft. long ft. long
Floor area�.5'-3�, sq. ft. sq. fr. sq. ft. sq. ft.
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Hgt.from grade i •-� 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 �5 C'C �� - �" � _.� J- ,f�c�-= E �
1. Enter lot dimensions and indicate north by arrow. Sign tur �dF �er or�u2 h�zed Agent:
2. Indicate the location and size of the requested constnzction �.,�C� '�-�
Signature
activities. � �
�PnnWame: Jv/n�. �� �r .� ��r«c�
3. Also, 1nd1C3te t$e IoCatlOn and d15tanCe to tlle Well, The above ceNfles ihat the listed infortnation and inten�ions are
We and corred.,that aIl work shall be peAormed in compliance
septic tank and drainfield, wetland areas, lot lines and to the wim me �eqw�emenes or tne sawyer co��ry zo���9 ord�nanc�
antl the laws and regulations of�he Sfate of Wisconsin, and if
CeritOTllriB Of thC I03d. acting as ownet(s)agent, has the permission of the owner(s)to
pedortn the work requested on this applicalion. The above
personsls hereby give permission for aceess to the propeiTy for
onsite inspecfion.
Permit fee: $ �o
August 11 2004 -
Issue Date Signature of Issu g g nt
August ll, 2005 50% Rule: AverageRoadSetback:
Expiration Date
Office Comments:
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SCALE: I INCH= 400 FEET FOR ASSESSMENT USE ONLY NOl
DRAWN BY: DATE : INTENDED TO SHOW CONCLUSIVE
COLON (:) INDICATES GOVT. LOT EVIDENCE OF OWNERSHIP OR
BOUNOARY LOCATIONS