HomeMy WebLinkAbout032-538-09-2303-LUP-2004-119 ���onctl US�
A lication for Lan��iJ���ermit(*Non-shore4 nd*) r �y� .
PP o /O
County of Sa��yer �, � .
PO Box 676 -Haywazd 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 boundaries. _ �
CONSTRUCTION SHALL NOT BEGIN UNTIL ALL REQUIRED PERMITS HAVE BEEN ISSUED. '
PRINT-USE BLACK INK OR PENCIL �
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Owner Builder <'
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Mailing Address ' Mailing Address O �
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City,State,Zip City,State,Zip
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Daytime Phone Daytime Phone
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Additional Information: Zone District: �
Lot Dimensions:
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Date lot was created: Acres: n
0
Is there wetland near the proposed structure?If yes,how faz G
Building Land Use Floodptain:� )Yes O No �
�')New ( )Filling �
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration (?�Grading O Private Rd O Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy �,`'', �
O O o S
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Primary Structure Accessory Building Acldition � °
(,)Dwelling ( )Garage-attached/detached (i�Deck W �
( )Yeaz round ( )#of caz stalls ( )Porch = —
O Seasonal O Storage Building O Enclosed � 9-'
O Frame built on site O Screenhouse O Living room U1
(;j Modulaz/manufactured ( )Greenhouse ( )Kitchen �,
( )Mobile/manufactured ( )Other ( )Bedroom � �
( )Other primary structure ( ) ( )Relocate/enlarge � '�
� � ( � ( )#of new �� �
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Additional Information: ���� � p��� �,,� �.g �,�t vi�i t5. - '
.�n �u:u y-�9-oy �
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Type of Construction: �,t �
( )Frame ( )Log ( )Pole/metal ( )Block ( )Concrete ��'
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( )Other ,�
�o �Construction Cost:Primary Structure$ `i ; ^ ' o
Accessory Building:$ Addition:$ �
3�yo9y � �
Deed:Vol Pg Certified Soil Test# n 3-�a9 °O Z
CSM:Vol Pg Lot# Sanitary Permit# � �''-�'' � �
=",� ����i,o�� ��-� �
Plat Envelope Or: ' � �,
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: � �
Previous office approvals/actions: �
Vaziance:# 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 addifion, each alteration in a separate column. � ��
#1. � ' � i f i ';;v . , #2. #3. #4.
Size_�_ft. wide fr. wide ft. wide ft. wide
' .� ft. long ft. long ft. long ft. long
Floor azea �� sq. ft. sq. ft. sq. ft. sq. fr.
Hgk from gcade 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 K ' �� ' i � ` � ' i � �
1. Enter lot dimensions and indicate north by arrow. Signa e wner or A d Agent:
2. Indicate the location and size of the requested construction
� Signature .
activities.
Print Name: � '
3. Also, 1ndlCate T.Ile IoCatlon and d1StanCe to tlle well, The above ceRifies Nat ihe listed infortnaUon and iNentions are
We and corred.,that all work shall be peAormed in wmpliance
septic tank and drainfield, wetland azeas, lot lines and to the with the requiremenis of ihe Sawyer County Zoning Ordinance
and Ne laws and regulations of ihe Shate of Wisconsin, and if
CeRtetllne of tlle To3d. acting as ovmef(s)agent has the permission of ihe owner(s)to
perfomi the work requested on this appliration. The above
personsls hereby give permission for access to the property for
onsite inspection.
Permit fee: $ a�C17°�
May 4_ 2004 —
Issue Date Signature ofIs in gent
May 4, 2005 50%Rule: AverageRoadSetback:
Expiration Date
Office Comments:
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