HomeMy WebLinkAbout018-837-14-1205-LUP-2004-466 f
Application for Land Use Permit(*Non-shoreland*) �/ 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 boundazies. �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. � '�
PRINT-USE BLACK INK OR PENCIL
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Owrier Builder <' �
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Mailing Address Mailing Address �
1/1��(a�/�/L ���7 �` �
City,State,Zip ' City,State,Zip
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Daytime Phone gV'i 5a(.�7a79 Daytime Phone
Additional Information: Zone District: ��'02 �� �
�y �
Lot Dimensions: Zf�l� X ��
Date lot was created: Acres: U���� n
0
Is there wetland near the proposed structure?If yes,how far �
Building Land Use Floodp}ain:� j I'es� O No ���
�New ( )Filling �
O Addition O Dredging Diiveway access off of a(Check one): �
O Alteration O Grading �Q Private Rd O Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy �, �
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Primary Structure Accessory Building Addition � °
( )Dwelling (�Garage-attached/detached ( )Deck W
O Year round (;�#of car stalls O Porch =
Stora e Buildin ( )Enclosed `�
( )Seasonal ( ) g g �
O Frame built on site O Screenhouse O Living room �
( )Modular/manufactured ( )Greenhouse ( )Kitchen �
( )Mobile/manufactured ( )Other ( )Bedroom �
O Other primary structure O O Relocate/enlarge 1
� � � � ( )#of new � �
AdditionalInformation: ' A
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�T e of Construction: �
Frame ( )Log ( )Pole/metal ( )Block ( )Concrete
( )Other ,.d y
Construction Cost:Primary Structure$ � �
c�n � I(,
(Accessory Building:$ �(1���. Addition:$ � I�
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Deed:Vol�Pg_�� Certified Soil Test#_zJ' ��0 °Q z
CSM:Vol Pg Lot# Sanitary Permit# ��—/�.� c, �
Plat Envelope Or: n� �
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Condo Vol Pg Year Installed: � �
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Aff of ex septic Vol Pg Owner When Installed:
Previous office approvals/actions:
Variance:# LUP:# 9(0—5'/'1 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
columa List each story, each addition, each alteration in a separate column.
#1. #2. #3. #4.
Size_�_ft. wide ft. wide ft. wide ft. wide
`f U ft. long ft. long ft. long ft. long
Floor area �11a� sq. ft. sq. ft. sq. fr. 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_/�yz 1 �/�CSS
1. Enter lot dimensions and indicate north by arrow. Signature of 0 ner or Authorized Agent:
2. Indicate the location and size of the xequested construction �(�� �C� � �����t
Signaryre
activities.
PrintName:���Ni]/�/f /��' STli�Y�/�
3. Also, 1ndlCate the IOCation &Tld dlstance to the Well, The above certifies that the listed iniormation and iNentiois are
true and correQ., that all work shall be performed in compliance
septic tank and drainfield, wetland areas, lot lines and to the w�m me req�ireme�cs or me sewyer co�ory zo���9 ord�oa�ce
and the laws and regulations of the State of Wisconsin, and if
Cente711ne Of tlle ToaC�. acting as owner(s)ageN,has the permission ot the owner(s)to
peAortn Me work requested on.ihis application. The above
personsls hereby give permission for access to the property for
onsite inspection.
Permit fee: $ /Q� �
S p mtQ 1iPr 1.. 9004 �� � `GcA - �-�XR_A�t 7�" _
Issue Date Signature ofIs in A ent —��
September 1, 2005 50% Rule: Average Road Setback: _
Expiration Date
Office Comments:
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FOR AS5�5SMt�ti't ifsf i .,; �
NOT tNTEPIDE�D TO SFip�41 :"-+-,�..
CWSIVE EViDENCE OF pb•yp���.
V W I • 3 7 N. , \ - � �+ �'- T ONS,OR $OUNDARY LOCA-
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