HomeMy WebLinkAbout020-638-01-3101-LUP-2004-167 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 ar 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. � _ ��
��f i�jQ. GLR1d PRINT-USE BLACK INK OR PENCIL y
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Owner ��r�e�vc���- T✓�S+ Builder
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Mailing Address Mailing Address O �
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City, State, Zip City, State, ip
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Daytime Phone Daytime Phone �
Additional Information: Zone District: /'# '1 �
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Lot Dimensions:
Date lot was created: Acres: �d.D n �--
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Is there wetland near the proposed structure? If yes, how far �
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Building Land Use Floadplain:O Yes ( j No :� �
( )New ( ) Filling �
�Addition O Dredging Driveway access off of a(Check one): �,
O Alteration O Grading O Private Rd �Town Rd. o
( ) Moving On ( ) ( ) County Hwy ( ) State Hwy N �
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Primary Structure Accessary Building Addition �� o
( ) Dwelling ( ) Garage-attached/detached ( ) Deck W
( ) Year round ( ) # of car stalls ( ) Porch �
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenhouse �iving room �
( ) Modular/manufactured ( ) Greenhouse ( ) Kitchen � �
( ) Mobile/manufactured ( ) Other ( ) Bedroom q� \ .-
( ) Other primary structure ( ) ( ) Relocate/enlarge � �
� � O O # ofnew ,� "�
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AdditionalInformation: �j A
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Type of Construction: ;�:�
�rame ( ) Log ( ) Pole/metal ( ) Block ( ) Concrete � �
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( ) Other
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Construction Cost: Primary Structure $ ��./tnp � �
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Accessory Building: $ Addition: $ � �;,
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Deed: Vol�Pg_��� Certified Soil Test# �"
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CSM: Vol Pg Lot# Sanitary Permit# � 7�
Plat Envelope Or: N
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Condo Vol Pg Year Installed: 1�ir�'or ,tp 1 QloR, �
Aff of ex septic Vol Pg Owner When Installed: % �
Previous office approvals/actions:
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Variance: # LUP: # SP: # CUP: #
Inspection Report: # Change of Zone District: �'NI�,.�
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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 . #2. #3. #4.
Size ^ ' ^ ft. wide ft. wide ft. wide ft. wide
-' ', ft. long ft. long ft. long ft. long
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Floor area .��?� '� sq. ft. 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 ;� r� r" � � '`- r r "�'
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1 . Enter lot dimensions and indicate north by arrow. Sign ur f er thorized Agent:
2. Indicate the location and size of the requested construction C '
Sig ture
activities.
Print Name:
3. Also, indicate the location and distance to the well, The above certifies that the listed information and intentions are
true and correct., that ail 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. a�t��s 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: $ !5
May 11 , 2004 -
Issue Date Signature of Is in gent
May 11 , 2 0 0 5 50% Rule: Average Road Setback: _
Expiration Date
Office Comments:
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