HomeMy WebLinkAbout010-941-25-2406-LUP-2004-462 . Application for Land Use Permit(*Non-shoreland*) o o ��
County of Sawyer �
PO Box 676 -Hayward 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. �
PRINT-USE BLACK INK OR PENCIL
, � � �
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Owner Builder �'
/0,2']9 A/ 4un r;S e �2« °
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Mailing Address Mailing Address � �
N ��r r l,.�Z S�eVs ;
City,State,Zip City,State,Zip
%
Daytime Phone Daytime Phone
Additional Information: Zone District:� I'� — �
Lot Dimensions: �"
— �_
Date lot was created: Acres: — .Uy n
0
Is there wetland near the proposed structure?If yes,how far � �
Building Land Use Floodplain:� }�es ( )No � :R
( )New ( )Filling � _
O Addition O Dredging Dxiveway access off of a(Check one): �
O Alteration O Grading O Private Rd �Town Rd. o
(=}Moving On ( ) ( )County Hwy ( )State Hwy �.w, �
O O o S
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Primary Structure Accessory Building Addition � °
( )Dwelling ( )Garage-attached/detached ( )Deck W
( )Yeaz round ( )#of car stalls ( )Porch =
( )Seasonal (�Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room � _
( )Modular/manufactured ( )Greenhouse ( j Kitchen - -�
( )Mobile/manufactured ( )Other ( )Bedroom �
( )Other primary structure ( ) ( )Relocate/enlarge
� � ( ) ( )#ofnew � �
Additional Information: p
�
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Type of Construction:
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(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete ���
( )Other _
ro �
Construction Cost:Primary Structure$ � �
Accessory Building:$ � � " Addition:$ �
m
Deed:Vol `)���� Pg � Certified Soil Test# a 3-3 q c� °Q z
CSM:Vol Pg Lot# Sanitary Permit# Q�- 5�85 �, 7�
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 ,� .
Vaziance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District: /��I�
�6 �
�-(3 q 81
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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.
#l. S� 31d� #2. #3. #4.
Size �, ft.wide ft.wide ft.wide fr.wide
�y ft.long ft.long ft.long ft.lon�
Floor area . ' sq.ft. sq.ft. sq.fr. sq.ft.
Hgt.from gc-ade to peak ft.hgt. ft.hgt. ft.hgt.
Stories stories stories stories
#of bedrooms
i Rear Lot Line I
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Fire Number and Name of Road I '�' �' � � �� � � �
1. Enter lot dimensions and indicate north by arrow. S' at e of�J!er or Au o zed Agent:
2. Indicate the location and size of the requested construction /�V . � +/(� 4�(/
Signature
2Ct1V1t10S. _ ' ��'
Pnnt Name: � ��` I��• ��
3. Also,IndlCate the loCahon 3IId dlstance to the Well, The above certifles thet the listed in omYe on and intentions are
We and correct.,ihat all work shall be p�dormed in compliance
septic tank and drainfield,wetland azeas,lot lines and to the w�m me requ�reme��or me sa�+ye�co��ry zoo��9 om��ance
and the laws and regulations of the State of Wisconsin,and if
Centerllne Of tlle T'oaC�. acting as ownel(s)agent,has the permission of the owner(s)to
perform ihe work requested on this application. The above
personsls hereby give pertnission for access to the property for
onsite inspection.
tL-=
Permit fee:$ ��
September 1, 2004 l n..c � � 1� i� — 1 D �'A
Issue Date Signature of Issu' g A nt ����—
September 1, 2005 50%Rule: Average Road Setback:
Expiration Date
Office Comments:
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