HomeMy WebLinkAbout002-940-16-1106-LUP-2004-366 Application for Land Use Permit(*Non-shoreland*) •
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County of Sawyer � �
PO Box 676 -Haywazd 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. �
"7/�}{�)/}iZ/� /"�IV�� PRINT-USE BLACK INK OR PENCIL �
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Owner Builder °'
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Mailing Address Mailing Address p
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City, at-`S�t e,Zip City,State,Zip �`
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Daytime Phone Daytime Phone
Additional Information: Zone District: �2-� �
Lot Dimensions:
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Date lot was created: Acres: J�J _5 c"� �
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Is there wetland near the proposed structure?If yes,how far .d i
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Building Land Use Floodplain:O Yes �No :;
( )New ( )Filling '�
¢�Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd �j Town Rd. o
O Moving On O O County Hwy O State Hwy ti
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Primary Structure Accessory Building Addition � �
(�)Dwelling ( )Garage-attached/detached (��Deck W
O Yeaz round O#of caz stalls (�Porch �.
( )Seasonal ( )Storage Building ( )Enclosed :»
O Frame built on site O Screenhouse O Living room
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( )Modular/manufactured ( )Greenhouse ( )Kitchen � -�
( )Mobile/manufactured ( )Other ( )Bedroom
( )Other primary structure ( ) ( )Relocate/enlarge � \
( ) ( ) ( )#ofnew � �
AdditionalInformation: �' 1
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Type of Construction: � �
(�'Frame ( )Log ( )Pole/metal ( )Block ( )Concrete ^
( )Other �
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Construction Cost:Primary Structure$ � �
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Accessory Buildine:$ Addition:$ �' (`�'"1, r» � r
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Deed:Vol 'f/ Yg�_ Certified Soil Test# q5— a3n °Q �
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CSM:Vol Pg Lot# � Sanitary Permit# L15 - 3ic"l �, �
Plat Envelope Or: N �
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: % �
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Previous office approvals/actions: "�
Variance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District 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 alteratio� in a separate column.
#L -1_1�� .�' •�=�>� �� #2. �:,r�"__ #3. #4.
Size_��ft. wide I G ft. wide ft. wide ft. wide
�.�ft. long i `� ft. long fr. long 8. long
Floor area�Q sq. ft. ���- sq. R. sq. ft. sq. ft.
Hgt.from giade�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 �'�1D�, \�1� �A ��1\ ������ ` �A
1. Enter lot dimensions and indicate north by arrow. Signatu�g of Owner or Au horized Agent:
2. Indicate the location and size of the requested construction -` _�_�� �Q�,�
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activities.
Pnnt Name: �� � C��C"�
3. AISo, 1ndlCate tjle loCatlon and dlStanCe to the Well, The above ceNfies that tie listed into i tion and intentions are
true and conect., that all work shall be rfortnetl in compliance
septic tank and drainfield, wetland areas, lot lines and to the w�m me req�ireme��s or me sewye� co��ry zo�m9 om��a�ce
and the laws and regulations of the State of Wisconsin, and if
COritCTllriO Of tt1C 702d. acting as owner(s)agent has the permission of the owner(s)ro
peAorm the work 2quesled on this application. The above
personsls hereby give permission for axess to the property for
��j�- onsite inspection.
Permit fee: $ ���
July 20, 2004 —
Issue Date Signature ofI s 'n gent
July 20,2 005
50% Rule: Average Road Setback:
Expiration Date
Office Comments:
OF BASS LAKE �
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