026-938-17-5725-LUP-2004-604 Application for Land Use Permit (*Shoreland*) o o .
County of Sawyer � � ' �
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PO Box 676 - Hayward WI 54843
715/634-8288 �
*Property that is located within 300' of a creek, river or stream or within 1000' of a �
flowage, lake or pond or has any of the above waterbodies located within
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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City, State, Zip City, S ate, Zip
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Daytime Phone aytime Phone
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Additional Information: one District: I`°�,��.. - �
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Lot Dimensions: �
Date lot was created: Acres: � , 40�
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Is there wetland near the proposed structure? If e3�s how far �jj, o
Building Land Use Floodplain: ( ) Yes ( )No �
O New O Filling Chippewa Flowage: O Yes O No 0
O Addition O Dredging Driveway access off of a(Check one): � ,;__
( ) Alteration ( ) Grading �Private Rd ( ) Town Rd. � �.
Count Hw State H �
( ) Moving On ( ) � � y y � � � o 0
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Primary Structure Accessory Building Addition o °
( ) Dwelling ( ) Garage-attached/detached J�Deck N
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O Year round O# of car stalls O Porch W
( ) Seasonal ( ) Storage Building ( ) 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
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AdditionalInformation: � �
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Type of Construction: � `
(� Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete �
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( ) Other '� �
Construction Cost: Primary Structure $ �..d
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Accessory Building: $ Addition: $ (� . ., � 'w
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Deed: Vol��Pg�_ Certified Soil Test# q�5��� � z
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CSM: Vol Pg Lot# Sanitary Permit# c!�'��� �. �
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Plat Envelope Or: �
Condo Vol Pg Year Installed: N �
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"Loads and Flows": Vol Pg Owner When Installed: �
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Previous office approvals/actions: �.�, 3� `' v
Variance: # LUr:# � z SP: # CUP: # � �
Chan e of Zone District: ��\
Inspection Report: # g
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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.
#I. #2. #3. #4.
Size 2 2' ft. wide i o� fr. wide ft. wide ft. wide �
�ft. long i I' fr. long fr. long ft. long
Floor area!D�y sq. ft. sq. ft• sQ• fr. S4� fr•
Hgt from giade to peak ft. hgt. fr. hgt. ft. hgt.
Stories stories stories stories
# of bedrooms
Lake/Pond/Flowa e/RivedStream Name
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FireNumberandNameofRoad �lol/9h� �GSII�/ PT �
1. Enter lot dimensions and indicate north by arrow. Signature of Owner o Au h rized Agent:
2. Indicate the location and size of the requested construction ,� ��1��¢ W���—
ignaNre
activities. -T �� �., -q.� 6o�,c/
PnntName:�µ,
3. Also, 1ndlCate the LOCation lild dl5tattce to the wel�, rhe a6ove certifies that the listed intormation and mtentions are
true and cortect., ihat all wo�C shall be performed in compliance
se tic tank and drainfield, wetland areas, lot lines, w�m me re�u��men�s or me sawyer co��ry zo�m9 om��a�ce
p and the laws and regulations of the S1ate of Wlsconsin, and if
CenteI'11ne of tI1C tOad 2Cld wateLbOdles. acting as ownef(s)agent, has the permission ot the owner(s)to
peAortn the work 2quested on this application. The above
personsls hereby give pertnission for access to �he property for
onsite inspedion.
Permit fee: $ � a S , ��
Total land area within 300' of the waterbody: (A) 11� �5
Total impervious surface azea [including this project] (B) ,� t �� 2 „7`1 zh
(B) /(A) x 100 =% Used z `�u (Shall not exceed 15%[or 25% with a conditional use permit].)
Shoreline Vegetation Protection Area: Mitigation Required? j�) Yes O No
October 21 , 2004 ' 7� —
Issue Date Signature of Iss ng ent
October 21, 2005 50%Rule: AverageRoadSetback: _
Expiration Date
Office Comments:
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SCALE : I INCH = FEET A M N U E ONLY NOT
DRAWN BY : DATE : INTEN�ED TO SHOW GONCLUSIVE
COLON (:) INDICATES GOVT. LOT BOIUNDARY LOGATIONS IP OR
SHORELAND PRF,SERVATION AGR�EMENT
(Non-Intact Shoreline Vegetation Protection Area)
Land Use Permit No. _ ��/ - (p0y (To be entered by the Zoning Office) Index No. �-�
� WHEREAS, (list all owners) ,/7��v `s� �/�gN/ .� C �cr ` y sG:S��L,-
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�1 owns real estate within Sawyer County that is subject to the Sawyer Counry Shoreland Regulations, and
� WHEREAS, in order to secure a Land Use Permit.
� NOW, THEREFORE, the owner(s) hereby certifies that, as a condition of issue of said Land Use Permit, that
� the SHORELINE VEGETATION PROTECTION AREA on said real estate shall be restored in accordance
� with the Mitigation Plan and Implementation Schedule approved by the Sawyer County Zoning Department.
�
� The owner(s) hereby agrees that at all times in the future, the real estate subject to this Agreement shall comply
� with all shoreland vegetative buffer requirements of the Sawyer County Zoning Ordinance in effect on the date
� that the Land Use Permit is issued by the Zoning Office. The owner(s) further agrees to allow authorized
N representatives of the Govemmental Unit to enter onto the owner's property at the following description to
mspect the structure(s) or uses authorized by said Land Use Permit and to determine if the SHORELINE
T VEGETATION PROTECTION AREA exists and that it is being preserved. Violation of this Agreement will
Q authorize, in addition to other penalties and relief requued under the Sawyer County Zoning Ordinance,
vo injunctive relief, restoration of said real estate, the revocation of said Land Use Permit and the removal of all
� structures approved by the issue of said Land Use Permit and the revocation of any other uses approved by the
�' issue of said Land Use Permit. All parties agree that this Agreement shall be filed with the Sawyer County
Q Zoning Office.
/� / / �"
Legal Description of Property: ��{j�/ � ��¢� C�/,D/" � "��' �� �lw,lu ,3�
9�^ � �a,,, a-«�-- p aG ' S'3� -/7 -.�'� • aS' f�rt���' � 2a—
Dated this �� day of ���
x �l�( I�), � I�tw ZuersCrtLL- —
(Ow ) / (Owner)
�/' � o �f/Lr ..�f� n�1N� �E7 Y t�'ELL— _
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wner) (Owner)
(Owner) (Owner)
This inshvment was dratted by:
Sa�ryer Counry Zoning Office .
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