HomeMy WebLinkAbout024-741-14-2202-LUP-2004-224 �,.
.'�pplication for Land Use Permit(*Non-shoreland*) ,
County of Sawyer ° � /�
PO Box 676 -Hayward WI 54843 V O
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. � �
�- �� f��y PRINT-USE BLACK INK OR PENCIL
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Owner , Builder �� �'
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�-�ailing Address M��`�ling Address ��p p
I���l�N K1�'n �-�-�� �������� Hp.��r J�2n �� �T'��� �
iry,St te,Zip City,Sta�e,Zip �
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Daytime Phone Daytime Phone
AdditionalInformation: ZoneDistrict �-/ � �
Lot Dimensions:
7
Date lot was created: . Acres: �j o �
Is there wetland near the proposed structure?If yes,how far � f,
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Building Land Use Floadplain:� j Yes O No :° �
Q ,�fe - ( )Filling '�
Addition O Dredging Driveway access off of a(Check one): � -�
( )Alteration ( )Grading ( )Private Rd ( )Town Rd. o (�
( )Moving On ( ) ( )County Hwy ( )State Hwy N �
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0
Primary Structure Accessory Building Additio � �
(�elling ( )Garage-attached/detached ( eck "'
w
( )Year round ( )#of car stalls ( )Porch �.
O Seasonal O Storage Building O Enclosed �
O Frame built on site O Screenl�ouse O Living room '
( )Modular/manufactured ( )Greenhouse ( )Kitchen � C�
( )Mobile/manufactured ( )Other ( )Bedroom
( )Other primuy structure ( ) ( )Relocate/enlarge � '
( ) ( ) ( )#of new �
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Additional Information: p
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Typ of Construction: �
(�rame ( )Log ( )Pole/metal ( )Block ( )Concrete � �
( )Other 1-'
-d �
3� � °' �
Construction Cost:Primary Structure$ , �
Accessory Building:$ Addition:$ � �(�
Deed:Vol _5�8 Pg Yfl7 Certified Soil Test# qy-,y31 °Q �z
CSM:Vol Pg Lot# Sanitary Permit# 9'�'3�03 � 7
Plat Envelope Or: i;, �
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: � �
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Previous office approvals/actions: •
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Variance:# LUP:# SP:# CUP:#
Inspection Report:# Change of Zone District: �,
5�a�1�
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Describe the construction using these columns. List the dimensions of each structure in a separate
colum 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
Floor area�CJ��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 ,
Lot Line or Lake/River name:
� _ .. ,
�---30 —
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Fire Number and Name of Road
1. Fill in lot dimensions and indicate north by arrow. Signature of Owner or Authorized Agent:
2. Indicate location and size of existing and new structures.
3. Indicate location of well, septic tank, drainfield.
4. Indicate distance to existing structures, lot lines, septic system.
5. Indicate distance to the ordinary high-water mark of any lake,
pond, river, stream, creek, and name the body of water. a��t Name:
The above cerfifes that Ihe listed informa6on and inlentions are
6. jI1d1C3t0 211}�gl2dlrig OI CIC321rig lri OXCCSS Of tI1C COriStIUCLIOri Slte. we and cottecL The above persons/s hereby give permission for
access to Ne property foronsite inspection.
7. Indicate distance to any wetland.
Permit Fee: Jr���
May 27 , 2004 ` - -
Issue Date Signature ofIss g nt
May 27 , 2005
Expiration Date
Office Comments:
Inspection Date: 50%Rule Applies: Avg. Setback: Within Reservation boundaries:
Restrictions and other information:
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TOWN OF ROIJf
SEC. 14 TWP 41 �J .
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