HomeMy WebLinkAbout010-941-20-1301-LUP-2004-426 Application for Land Use Permit(*Non-shoreland*) o o -
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 REQUII2ED PERMITS HAVE BEEN ISSUED. � z
PRINT—USE BLACK INK OR PENCIL �
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Owner Builder �er�,See, <.
9� .)esf Shm� �ue o� �.� .
Mailing Address Mailing Address � � �
/j?ad,srn, CJ� 53 7.�5-l8/8 1 (�I�l� w e s7 s�n.� �7� �
Cit ,State,Zip City,State,Zip �
y� og-z56- 759/
,�c,.� �-�74- io69 �/A ��ArrD w.2 <5�/$�/� o
Daytime Phone •Daytime Phone 1
�,�, 3�i9, i� /9�s
Additional Information: Zone I�istrict: /f� �
- '�ot Dimensions:
�
Date lot was created: Acres: yd o t/'
Is there wetland neaz the proposed structure?If yes,how faz l� � �n
� �B ilding Land Use Floodptain:� j Yes O No `;
New i10� ( )Filling 'k
)Addition ��� O Dredging Driveway access off of a(Check one): CD
ao
O Alteration O Grading O Private Rd O Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy �,"j �
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Primary Structure Accessory Building Addition � r
0
�Dwelling ( )Garage-attached/detached ( )Deck W
( )Yeaz round ( )#of caz stalls ( )Porch �
( )Seasonal ( )Storage Building ( )Enclosed `D
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O Frame built on site O Screenhouse O Living room �
( )Modulaz/manufactured ( )Greenhouse ( )Kitchen
�Mobile/manufactured ( )Other ( )Bedroom \
( )Other primary structure ( ) ( )Relocate/enlarge �
( ) ( ) ( )#of new � �
AdditionalInformation: 1 �
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Type of Construction:
( )Frame ( )Log ( )Pole/metal ( )Block ( )Concrete �
( )Other
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Construction Cost:Primary Structure$� /�0�7 � �
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Accessory Building:$ Addition:$ � ..�
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Deed:Vol rf�Pg y�r] Certified Soil Test# Qz'UC(o °4 z
CSM:Vol Pg Lot# Sanitary Permit# Jz'C�{z, �, 7�
Plat Envelope Or: N �
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: % �
Previous office approvals/actions: �
Variance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District:
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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. c.J #2. 17e c,K #3. #4.
Size � ft. wide (a ft. wide ft. wide ft. wide
8D ft. long �� ft. long ft. long ft. long
Floor area t�So sq. ft. �'`�0 sq. ft. sq. ft. sq. ft.
Hgt.from grade 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 ��70 JV ('c�c� �0.�
1. Enter lot dimensions and indicate north by arrow. ' ature�0 n r or thori d Agent:
2. Indicate the location and size of the requested construction
Signature
1Ct1V1t1eS. Print Name: � 2' ���"��
3. Also, indicate the location and distance to the well, The above certifies that the listed infortnation and intentions are
true and correct.,that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines and to the with the requirements of the Sawyer County Zoning Ordinance
and the laws and regulations of the State of Wisconsin, and if
centerline of the road. aot��9 as ow�er�s�a9e�t, has the permission of the owner(s)to
perform the work requested on this application. The above
persons/s hereby give permission for access to the property for
onsite inspection.
Permit fee: $ ` ��"% X�•� - �.���-��
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Issue Date Signature of Is in gent � �
�;a,�_.,, :� �'� � � ;���:; 50% Rule: Average Road Setback:
Expiration Da`�e
Office Comments:
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