HomeMy WebLinkAbout024-841-12-3424-LUP-2006-074 Application for Land Use Permit: (*Non-shoreland*) o o�•
County of Saw�,�er � �
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PO Box 676 - Hayward �VI 54843
715/634-8288
*Property that is not located within 300' of a creek, river or stream or within 1000' of a c �
flowage, lake or pond or does not have any of the above waterbodies located within j
the property's boundaries. °"
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL RE��UIRED PERMITS HAVE BEEN ISSUED. � �
PRINT-USE BLACK INK OR PENCIL �'
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Owner Build��r ¢'
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Mailing Address Maili�ig Address �
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City, State, Zip City, State, Zip
Daytime Phone l�� h � �SS Daytim� Phone
1- �
Additional Information: Zone District: � �`�
Lot Dimensions: �
Date lot was created: Acres: Z � 7� o �.
Is there wetland near the proposed structure? If yes, how far � �
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(�uilding Land Use Floodplain: ( ) Yes ( )No :�
New ( ) Filling �
O Addition O Dredging Driveway access off of a(Check one): �,
O Alteration O Grading O Pr•ivate Rd O Town Rd. o
�1Vloving On ( ) ( ) Cuunty Hwy ( ) State Hwy N �
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Primary Structure Accessory Building Addition � �
( ) Dwelling ( ) Garage-attached/cietached ( ) Deck W
( ) Year round ) # of car stalls ( ) Porch �
( ) Seasonal (� Storage Building ( ) Enclosed �°
( ) Frame built on site ( ) Screenhouse ( ) Living room � �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen R�
( ) Mobile/manufactured ( ) Other ( ) Bedroom .-
( ) Other primary structure ( ) ( ) Relocate/en�arge �
� � ( ) ( ) # of new Qp �
1
AdditionalInformation: .� A
N U,
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Type of Construction: �
�,Frame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete �
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( ) Other
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Construction Cost: Primary Structure $ ���c � �
Accessory Building: $ A��dition: $ �
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Deed: Vol Y�Pg ?5 Certified Soil Test# 83-25/!� U4 z
CSM: Vol P Lot# Sanitary Permit# 83-Z.o y � 7�
,[o�' 3 (, d►�o �`�25 Or: �
Plat Envelope N
Condo Vol 83y�g Year Installed: c� �
Aff of ex septic Vol Pg y, Owner When Installed: `-' �
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Previous office approvals/actioiis:. �,a39�'y N
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Variance: # LUP:"#,_ dD-58`� SP: ;� CUP: # (N
Inspection Report: # O!-�`� ``" Change of Zon.e ]�istrict:
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Describe the construction using these columns.Lis1:the dimensions of each structure in a separate
column.List each story,each addition,each alteration in a separate column.
#L �;�; #2. #3. #4.
Size � z o ft.wide ft.wide ft.wide ft.wide
�fr.long ft.long ft.long ft.long
Floor area��sq.ft. sq.ft. sq.ft. sq.ft.
Hgt.from gade (`��to peak ft.hgt. ft.hgt. fr.hgt.
Stories_�� stories stories stories
#of bedrooms
Rear Lot Line
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Fire Number and Name of Road l z�/z6 W 7w�n L.a Ke l�vn,d
1. Enter lot dimensions and indicate north by arrow. Slgnature of Owner or Autho�lzed Agent:
2. Indicate the location and size of the requested construction �,l��. (�,�.,��„�,r�2*�`
Signa
activities.
Print Name:
3. A�So,lnc{1C3te tlle locatlon and dlstanCe to the Well, The abave cerGfies tha�the listed information and intentlons are
We and coned.,that all work shall be pedortned in compliance
� Sept1C tal]IC attd dralnf ela,Wetland aT'eas,lot lines 817d to the with ihe requirements of the Savryer Counry Zoning Ordinance
and the laws and regulations of the State of Wisconsin,antl if
Centerllne of tlle road. acting as ownef(s)agent,has the pertnission of the owner�s)to
perform lhe work requested on this appiication. The above
personsls hereby give pertnission for aaess to the property(or
onsite inspection.
Permit fee:$ �s��
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Issue Date Signature of Iss 'ng nt �—-�—�
�,pn 1� ���,Z.� / 50%Rule: Average Road Setback:
Expiration Date
Office Comments:
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