HomeMy WebLinkAbout016-637-06-2301-LUP-2004-514 . Application for Land Use Permit(*Shoreland*) 17o�S ��t r ,�
0 0 �County of Sawyer �`��j�=1� �
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 boundaries. �;.
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. �' �
PRINT-USE BLACK INK OR PENCIL '
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Owner Builder o- c�
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1Vlailing Address Mailing Address � p �
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City,State,Zip City,State,Zip
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Daytime Phone Daytime Phone �
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AdditionalInformation: ZoneDistrict f�q'"��
Lot Dimensions:
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Date lot was created: ,-�uG� / �f��,� Acres: �fC' �
Is there wetland neaz the proposed structure?If yes,how far o r�'.,
Building Land Use Rloodplain:O Yes (�No �
(�Lj New O Filling Chippewa Flowage:O Yes O No �
O Addition O Dredging Driveway access off of a(Check one): x�
( )Alteration ( )Grading ( )Private Rd ( )Town Rd. �
( )Moving On ( ) ( )County Hwy ( )State Hwy °Q
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Primazy Structure Accessory Building Addition p �
�Dwelling ( )Garage-attached/detached ( )Deck � �
O Year round O#of caz stalls O Porch �,
( )Seasonal ( )Storage Building ( )Enclosed �
O Frame built on site O Screenhouse O Living room co �
( )Modulaz/manufactured ( )Greenhouse ( )Kitcben � 1
( )Mobile/manufactured ( )Other ( )Bedroom
( )Other primazy structure ( ) ( )Relocate/enlarge _ �
( � ( ) ( )#ofnew
Additional Information: ,'
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Type of Construction: � �
(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete
( )Other ,� „�
Construction Cost:Primary Structure$ �C C' , C C C' � �
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Accessory Building:$ �Addition:$ w
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Deed:Vol 7 c 7 Pg �� _ Certified Soil Test# ��/ �; ;� z
CSM:Vol Pg Lot# Sanitary Permit# O`! �� � `�' �
Plat Envelope Or: y� �
Condo Vol Pg Year Installed: N
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"Loads and Flows": Vol Pg Owner When Installed: �
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Previous office approvals/actions: c� �
Variance:# LUP:# SP:# CUP:# �T1�
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
�cyo1lum��n.,�La^ist/eJach story,each�{�afdd/�itionn,eac♦h alteration iny�a separate column. A /� •
ttl. f.T-S� /JA/F/���.i.� itG. /'//`ST /�Lce�C tt3. S/Ga'H� I'C_�ci2 �Y. ��� JI
Size 2iC � ft.wide �r' ft.wide 30� ft.wide _L6'�ft.wide
6�c , ft.long �c , ft.long ��, ft.long �f�0 � ft.long
Floor area c c� sq.ft. C� sq.ft. qcc>.,.,-sq.ft. o C' sq.ft.
Hgt from grade 3,�to pealc_� ft.hgt. !C� , ft.hgt. ft.hgt.
Stories�_ stories stories stories
#of bedrooms 3
� "��� �� '�'��'"� Lake/Pond/Flowa eBiver/Stream ame 7���,,. /' OF o ti✓�
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Fire Number and Name of Road � �j ��/ .0 �c ��/���ti ����
1. Enter lot dimensions and indicate north by arrow. Si t f-D� Authorized Agent:
2. Indicate the location and size of the requested construction - - - "
�� G �SignaNre
activities. - // //
PrintName: �f��:��ti� Z /'!L il�.�/�
3. Also,1ndlCate the loCatlon and d15tanCe to the well, ihe above certifes that the listed Intormation and intentio�s are
hue and corred.,that ail wolrc shall be pedormed in compliance
septic tank and drainfield,wetland areas,lot lines, w�m me r�wremeo�s or tne sawyer co���y zoo�o9 om��ance
and the laws and regulalions of Ne State of Wisconsin,and if
centerline of the road and waterbodies. 1 ac���s as owr�er�5�a9e�t nas me Perm�s5�o�or me owoer�5�to
������i'� !.10'F� nU�� perform the work requested on Ihis application. The above
�.�,,,;�;-�. (;,,•. i�--�n i _. , personsls hereby give permission(or access lo the property for
onsiteinspection.
Permit fee:$ ��'r).�'``�
Total land area within 300'of the waterbody:(A)
Total impervious surface area[including this project](B)
(B)/(A)x 100=%Used (Shall not exceed I S%[or 25%with a conditional use permit].)
Shoreline Vegetation Protection Area:Mitigation Required?O Yes (�No
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SEptember 16 2004 _ �' � L/
Issue Date Signature of Issuing Agent
SEptember 16, 2005 50%Rule: Average Road Setback: _
Expiration Date
Office Comments:
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