HomeMy WebLinkAbout010-840-36-5320-LUP-2004-151 _�
Application for Land Use Permit���*) r ,� •
County of Sawyer ° � `—
PO Box 676 -Haywazd WI 54843
715/634-8288 � �
*Property that is located within 300'of a creek,river or stream or within 1000'of a
flowage,lake or pond or has any of the above waterbodies located within
the property's boundazies. ,; �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUiRED PERMITS HAVE BEEN ISSUED. �
PRINT-USE BLACK INK OR PENCIL
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Owner �, Builder a �
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Mailmg Address ailing Address � O
,j Gr/1 /� � � i,��
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City,State,Zip Cit�te,Zip �`
� � = � ��is� -���rs �% i33 �.
Daytime Phone Daytime Phone �\
Additional Information: Zone District: '`-�---7, " RR� �
Lot Dimensions: � ��
Date lot was created: �`�` Acres: �� �' ,/.<.>, ' � 5-�� ��, �
Is there wetland near the proposed structure?If yes,how far o �=\
Building Land Use Floodplain:O Yes (Y_}No C �
New O Filling Chippewa Flowage:�Yes O No �
( Addition O Dredging Driveway access off of a(Check one): �
O Alteration (t�Grading O Private Rd �)Town Rd. ?
( )Moving On ( ) ( )County Hwy ( )State Hwy °Q
� ) � ) � S
Primary Structure Accessory Building Addition o 0
('�(Dwelling (vYGarage-attached/detached ( )Deck �
(f�'Year round ( )#of caz stalls ( )Porch �, (�,
( )Seasonal ( )Storage Building ( )Enclosed �
(�Frame built on site O Screenhouse O Living room co
( )Modular/manufactured ( )Greenhouse ( )Kitchen �
( )Mobile/manufactured ( )Other ( )Bedroom p �
O Other primazy structure O O Relocate/enlazge c
� � O O#ofnew
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AdditionalInformation: - a
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Type of Construction: �
(�'Frame ( )Log ( )Pole/metal ( )Block ( )Concrete
( )Other ,�
Construction Cost:Primary Structure$ ��v ✓!'l� ,.d �
Accessory Building:$ Addition:$ ^ �
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x �
Deed:Vol_��Pg�_ Certified Soil Test# �y'U`�U � z
i �
CSM:Vol Pg Lot# Sanitary Permit# 0 y-G';o � � %`�
Plat Envelope Or: a, �`.
Condo Vol Pg Year Installed: N I
"Loads and Flows": Vol Pg Owner When Installed: � �
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Previous office approvals/actions:
,
Variance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District: ` 5/c�/b`�
Ha�l$o
/ .
.; ,
Describe the construction using these columns. List the dimensions of each structure in a separate .
colum�n�. �is't�each story, each addition, each alteration in a separate column.
#1. #2. �Q,«� � #3. #4.
Size��ft. wide ..9n ft. wide ft. wide ft. wide
��ft. long a� fr. long ft. long ft. long
Floor azea �� sq. ft. r/o� sq. ft. sq. ft. sq. ft.
Hgt from giade�_to peak ft. hgt. fr. hgt. ft. hgt.
Stories__� stories stories stories
# of bedrooms�
Lake/Pond/Flowa e/River/Stream Name
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Fire Number and Name of Road �1 .H,t
1. Enter lot dimensions and indicate north by arrow. Signature of Owner or Authorized Agent:
2. Indicate the location and size of the requested construction -
, Signature
activities.
Print Name: � �
3. Also, 1ndiCate tlle IoCatlon and d15tanCe to the Well, The a6ove certifies Nat the listed intormation and intenuons are
We and correct., Nat all work shaii be perfortned in compliance
SeptlC tank and dTalnfield, wetland areas, lot 11nes, with me requirements ot the Sawyer County Zoning Ordinance
and Ne laws and regulations of the State of Wisconsin, and 'A
centerline of tkle road and waterbodles. acting as owner(s) aqent, has tne permission of tne owner(s)to
peAorm the work requested on Nis application. The above
personsls hereby give permission for access to the property for
ons@e inspection.
Permit fee: $ ��J<J ' . �'"�;,.,,.
Total land area within 300' of the waterbody: (A)
Total impervious surface area [including this proje (B
(B) / (A) x 100 = % Used (S 1 not excee 5%[or 25% with a conditional use permit].)
Shoreline Vegetation Protection Area: Mirigation Required? O Yes O No
�� �_ - �
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Issue Date _� �^ Signature ofIss i g nt
�j j n I�,� 50% Rule: Average Road Setback:
Expiration Date t�`��
Office Comments:
vi .� c_�. t I VIV JV ' 1 YVI� - R �Y7
� TOWN OF HAYWARD SAWYER COUNTY - WISCONSIN . �"'
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INCH =400 FEET FOR ASSESSMENT USE ONLY NOT
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DATE � INTENDED TO SHOW GONCLUSIVE
:) INDIGATES GOVT. LOT 80UNOARY�LOCATIONS 'P �R
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