HomeMy WebLinkAbout002-154-00-0900-LUP-2003-656 AM���n� �
Application for Land Use Permit(*�1���*-) r y �
County of Sawyer �``s ��°'�'�' ��� ° �
PO Box 676 -Hayward 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 � �
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the property's boundazies. C- ,�
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED.
PRINT-USE BLACK INK OR PENCIL
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Owner Builder p:
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Mailing Address Mailing Address a O
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City,State,Zip City, tate,Zip
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Daytime Phone Daytime Phone � ;
Additional Information: Zone District hi�'� �
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Lot Dimensions: _ `
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Date lot was created: Acres: I,�%''� �
Is there wetland neaz the proposed structure?If yes,how faz 7� �� �.W� � ���"���S n �J
Building Land Use Floodplain:O Yes (JU No G f-. �
(ycXNew ( )Filling Chippewa Flowage:( )Yes (� No �c
O Addition O Dredging Driveway access off of a(Check one): z�
O Alteration O Grading O Private Rd Qy Town Rd. ?
( )Moving On ( ) ( )County Hwy ( )State Hwy °Q
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Primary Structure Accessory Building Addition o 0
(�Dwelling �}L'7arage-attache deta ' ( )Deck �
(�Year round (y�#of car stalls�3� O Porch W
( )Seasonal ( )Starage Building ( )Enclosed �,
O Frame built on site O Screenhouse O Living room �o
( )Modular/manufacYured ( )Greenhouse ( )Kitchen ,•",
( )Mobile/manufactured ( )Other ( )Bedroom _
( )Other primary structure ( ) ( )Relocate/enlazge - \
� � ( ) ( )#ofnew �,
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Additional Information: ��G "��tM��+� �Q��t � >
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T e of Construction: i �,;�
(�Frame ( )Log ( )Pole/metal ( )Block ( )Concrete ^
( )Other � ,�
Construction Cost:Primary Structure$ � ,d �
Accessory Building:$ �f��6�� Addition:$ o �
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Deed:Vol 5�:' Pg� Certified Soil Test# L� > - _>�� � z
CSM:Vol Pg Lot# Sanitary Permit# (����yl� 00 7y
Plat Envelope Or: o� �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: ��
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 additjon, each altgration in a separate column.
#1. C'�ikRr��c #2. �7ifi�v" t ��f' #3. #4.
Size ',�G ft. wide �/ . wide ft. wide fr. wide
�O ft. long G� ft. long ft. long fr. long
Floor area� sq. ft. CC� sq. ft. sq. ft. sq. ft.
HgG fmm grade 1 � to peak �� fr. hgt. ft. hgt. ft. hgt.
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Stories �� �stories stories stories
# of bedrooms�_
Lake/Pond/Flowa e/River/Stream ame
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Fire Number and Name of Road 1 �� �� � aot d �
1. Enter lot dimensions and indicate north by arrow. j of t7 er or Aut�iorized Agent:
2. Indicate the location and size of the requested construction +"�- �� t I
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activities. . l
� rint Name:
3. Also, indlcate the location and distance to flle well, The above certifes that me Iisted intormation and intenuons are �
We and conect.,that all work shall be pertortned in compliance !
septic tank and drainfield, wetland azeas, lot lines, with Ne requiremenis of ihe Savryer Counry Zoning Ordinance
and ihe laws and regulations of the SFate of Wisconsin, and if
centerline of the road and waterbodies. a�e�9 as owner�5�a9e�t nas cne Pe�nSs�o� or me owoert5)io
peAorm ihe work 2quested on this applicatioa The above
personsls hereby give pertnission for access to lhe properry for
onsite inspedion.
Permit fee: $
Total land azea within 300' of the waterbody: (A)
Total impervious surface azea [including this project) (B)
(B)/(A) x 100 = % Used (Shall not exceed 15%[or 25% with a conditional use permit].)
Shoreline Vegetarion Protection Area: Mitigation Required? O Yes O No
May 19 , 2004 -
Issue Date Signature ofIss g ent
May 19 , 2 0 0 5 50% Rule: Average Road Setback:
Expiration Date
Office Comments:
SCALE 1 ��= 200 � '
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4 / 190 — — — - - — - - - - -- - - - - - - -- ,
-T I Prt ' Lot 2 �
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SCALE : i INCH = FEET FOR ASSESSME
DRAWN BY : �K DATE � ro�q �83 INTENDED TO
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