032-540-30-3107-LUP-2004-692 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 PERMITS HAVE BEEN[SSUEA '
PRINT-USE BLACK INK OR PENCIL
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Owner Builder� U��'��f <'
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Mailing Address Mailing Address O
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City,State,Zip City,State,Zip �.�.
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Daytime Phone Daytime Phone
Additional Information: ��'• Zone District:
Lot Dimensions:
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Date lot was created: Acres: 5 3R n
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Is there wetland near the proposed structure?If yes,how far �
Building Land Use Floodptain:� )I`es O No �
�New ( )Filling �
Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd O 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 (j)#of car stalls O Porch =
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse O Living room
( )Modular/manufactured ( )Greent�ouse ( )Kitchen
( )Mobile/manufactured ( )Other ( )Bedroom
( )Other primary structure ( ) ( )Relocate/enlarge \
� � ( ) ( )#of new
Addition���fo�at�1 � �� ���,�� �,,,�p a
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Type of Construction: �
( )Frame ( )Log (1�'Pole/metal ( )Block ( )Concrete -
( )Other
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Construction Cost:Primary Structure$ � �
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Accessory Building:$ Addition:$ �
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Deed:Vol !v0 Pg 3=� Certified Soil Test# �_ttT ) tlQ z
CSM:Vol�Pg �zB Lot# /$ Sanitary Permit# .$�,2 O`�l-`f�1Co o, ,'�
Plat Envelope Or: i,, I
Condo Vol Pg Year Installed: �
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Aff of ex septic Vol Pg Owner When Installed:
Previous office approvals/actions: �_
Variance:# LUP:# Qp—55a SP:# CUP:#
Inspection Report:# Change of Zone District: Id`I
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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. Hpcc6� #2. r c R-1A�7 e #3. ti #4. �
Size - ft.wide I(c�a _�_ .�de ft.wide •
j�j -�-- $,�ng �ft.long 3C, ft.long ft.long ,
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Floar area�sq.fr. �`/ sq.fr. �y� SQ•fr� Sq'ft'
Hgt from gade ,�` ' to peak f 1 ft.hgt. fr.hgt. ft.hgt.
Stories � / stories stories stories �
#of bedrooms �
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Rear Lot Line ; '
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W � 4
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�!� �c%�LL nN� 5e�ro�in:sTtu�v ourh Krfi
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Fire Number and Name of Road
l. Enter lot dimensions and indicate north by arrow. Signature of Owner or Authorized Agent:
2. Indicate the location and size of the requested constnzction � � f ��s�u...�.o� _
SignaNre
1CtiV1t105. pnntName:' � � r �
3. Also,1ndlCSte t11C IoCBtlon and d1StanCe to tlle we�l, The above ceAifies that the listed intormallon and intentions are
true and cnrted.,that all work shall be pedortned in compllance
Se t1C tank ancl dTalnfield,wetland azeas,lot 11nes and to the wit�the requiremenis of ine Savryer Counry Zoning Ordinance
P and lhe laws and regulalions of the State of Wiscronsin,and if
CenteTllne Of the TOad. acting as ownel(s)agent,has the permission of the owner(s)to
perform Me work requested on this application. The above
personsls hereby give permission for access to Ne property for
onsiteinspec6on.
Permit fee:$ ���.� �17Sx��
December 28, 2004 �� ���t P :f`C�t..f -�ID � � L�
issue Date S;g:.atu.e of Is iir. . gent (�
December 28, 2005 50%Rule: AverageRoadSetback: _
Expiration Date
OfficeComments: —��r\1S {�P���'� �S �� `��� ���'�� �—��"� � � •
Sawyer County Zoning Administration
Inspection Report �
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Owner E�ene ��-+��s"�<r � 6Z. _ 82-0 — 0160
Address W 240 � d859 �10 12c1 4 Suss*�n �I S3S�OQ (n11
Agent/Purchaser �
Address ,�
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Blder/Plber/CST
Address
Inspection ( ) Dwelling ( ) Setback - lake
( ) Mble Hm ( ) Setback - road
( ) Private ( ) Public ( ) Commercial ( ) Setback - lot line
( ) Garage ( ) Soils Verif r,
Violation ( ) Addition ( ) � o
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(�C1 Zoning ( ) Sanitation "
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NOTE ! Deed gaps aqd \ SCALE: I INCH=400 FEE'
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