030-737-27-2103-LUP-2004-121 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 �
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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Own�r Builder �: �
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Mailing Address Mailing Address � �
�Xe o�►e,l l,t�Z' �S/�3� �
City, State, Zip City, State, Zip �
7/5�� �7/.� �
Daytime Phone �C�� t - ,� � Daytime Phone �,.
itional Information: � Zone District: � c,r��i.•� / .
Add ������
Lot Dimensions: �� � � �/� ��
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Date lot was created: � �� �C��`f Acres: (,��� n t
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Is there wetland near the proposed structure? If yes, how far �
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Building Land Use Floodplain:( j Yes �j No �
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�j New ( ) Filling �
O Addition O Dredging Driveway access off of a(Check one): a,
( ) Alteration ( ) Grading ( ) Private Rd ( ) Town Rd. o
O Moving On O O County Hwy O State Hwy ti
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Primary Structure A ces Building Addition � °
�Dwelling � ara -attache_d/detached ( ) Deck W
( ) Year round (3) of car stalls ( ) Porch �
( ) Seasonal ( ) Storage Building ( ) Enclosed � �
( ) Frame built on site ( ) Screenhouse ( ) Living room � �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen Q
( ) Mobile/manufactured ( ) Other ( ) Bedroom w --
( ) Other primary structure ( ) ( ) Relocate/enlarge � '
� � � � ( ) # of new '
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Additional Information: �
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Type of Construction: � �
�Frame ( ) Log ( ) Pole/metal ( ) Block � Concrete a.
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( ) Other � �
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Construction Cost: Primary Structure $ 7� `7�J�-' �
Accessory Building: $ �L'�� Addition: $ � �J
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Deed: Vol Pg _..TL ��G `� �� Certified Soil Test# � �-� - ;�� ;,,,�, � z
CSM: Vol� ' Pg Lot# Sanitary Permit# - � 1 "" �� �� � o� �
Plat Envelope Or: ���fi�v e- �c��afi p�u w.�L) �,
I 'v,
Condo Vol Pg Year Installed: � �
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Aff of ex septic Vol Pg Owner When Installed: "
U,
Previous office approvals/actions: �
Variance: # LUP: # SP: # CUP: #
Inspection Report: # Change of Zone District: �I��e�
3 ��'1 $
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. �r�c�-, #3. #4.
Size I�l ft. wide 3� ft. wide� ft. wide ft. wide
3c1 ft. long a� ft. long ft. long ft. long
Floor area � "Sq�� sq. ft. sq. ft. sq. ft.
Hgt.from grade 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 s'�4�-
1. Enter lot dimensions and indicate north by arrow. Signat re of Ow er or Authorized Agent:
2. Indicate the location and size of the requested construction � C-'
Signature
activities.
PnntName: •�i. �"�y'
3. Also indicate the location and distance to the well, The above certifies th 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. a�t��s as oW�er�s�a9e�t,has the permission of the owner(s)to
perform the work requested on this application. The above
personsls hereby give permission for access to the prope�ty for
onsite inspection.
Permit fee: $ o� c��- ��
rlay 4, 2004 - ��
Issue Date Signature of Iss 'ng ent
May 4, 2005 50%Rule: Average Road Setback: _
Expiration Date
Office Comments: �
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