026-939-17-5124-LUP-2000-165Application for Land Use Permit — Page 2
Describe Construction: List dimensions of each structure, story, addition, or alteration.
# 1. #2. #3.
Size ft. wide ft. wide ft wide
Q C-) ft. long
Floor area Y 0 sq. ft.
Hgt. from grade to peak
Stories
# of bedrooms
In the box sketch in:
Location and size of all
existing and proposed structures.
Location of septic system.
Indicate distance to:
Waterline/Wetlands
Road
Lot lines
Septic system/privy
Well
Distance between structures.
Indicate North.
Fire Number:
p�lfivt �^
ignature of Owner
The above certifies that the listed
information and intentions are true and
correct. The above persons/ hereby
give permission for access to the
property for onsite inspection.
Issue Date May 11, 2000
Office Comments:
ft. long
sq. ft.
ft. hgt.
stories
ft. long
sq. ft.
ft. hgt.
stories
#4.
ft. wide
ft. long
sq. ft.
ft. hgt.
stories
rear lot line or waterline of SQ L4 d L�— Q-- lake/river
-,tip "� t��fti
a
d
L �1
0
------- centerline of s T14 7
Expire Date May 11, 2001
Signature 0 Zoning Administrator
road -------