HomeMy WebLinkAbout032-540-27-4102-LUP-2004-634 Application for Land Use Permit(*Non-shoreland*) o 0
County of Sawyer �, � �
PO Box 676 -Hayward WI 54843 �
� �`� 715/634-8288 �
*Property that is not located within 300'of a creek,rivex 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.
�Q��p' Q� PRINT—USE BLACK INK OR PENCIL ,
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Owner Builder �'
(,�/8's�� (�o�u�l{. �d. � �� Kn oo(�. kd. �� I
Mailing Address Mailing Address O �
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City,State,Zip City,State,Zip � �
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Daytime Phone Daytime Phone � �y
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Additional Information: Zone District:
Lot Dimensions:3 3D��' �3 a�' �'j
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Date lot was created: Acres: �� o �
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Is there wetland near the proposed structure?If yes,how faz � U�� �
Building Land Use Floodptain:� J Yes (�No �
(�New ( )Filling �,
O Addition O Dredging Driveway access off of a(Check one): �
O Alteration O Grading O Private Rd QO Town Rd. o
( )Moving On ( ) ( )County Hwy ( )State Hwy ; �
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Pr'mary Structure Accessory Building Addition � °
Dwelling ( )Garage-attached/detached ( )Deck W �
O Year round O#of car stalls QQ Porch = �
Q�Seasonal O Storage Building O Enclosed � �
O Frame built on site O Screenhouse O Living room �
( )Modular/manufactured ( )Greenhouse ( )Kitchen (�l
( )Mobile/manufactured (X)Other ( )Bedroom �
O Other primary structure O YP—�a�l O Relocate/enlarge �
� � ( ) �� ( )#of new G! �
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AdditionalInformation: 1�` p
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Type of Construction: �C �
( )Frame ( )Log ( )Pole/meta] ( )B1ock ( )Concrete � .�
(.�Other 7i�nheP �i�c�.rt�. �'
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Construction Cost:Primary Structure$�, g 0�.--- �+ �
Accessory Building:$ Addition:$ � O
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Deed:Vol '7�! � Pg� Certified Soil Test# tlQ
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CSM:Vol Pg Lot# Sanitary Permit# O y-034 P,-t u� o, �
Plat Envelope Or: N �
Condo Vol Pg Year Installed: �
Aff of ex septic Vol Pg Owner When Installed: % �
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Previous office approvals/actions: �,�
Variance:# LUP:# SP:# CUP:# N
Inspection Report:# Change of Zone Disttict nl��
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3�1�+�
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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,t each alteration in a separate col n.
#1.Mo��v� ��oOr #2. LD 'Yt #3. #4. ,
Size��ft. wide o'�O ft. wide . wide fr. wide
3 0 ft. long � a ft. long ft. long ft. lopg,
Floor area �0�� sq. ft. a.�� sq. ft. sq. ft. sq• fr.
Hgt.from grade�to peak 1 D ft. hgt. ft. hgt. ft. hgt.
Stories � ��o� �l� stories stories stories
# of bedrooms_J__ z
��i�<x � ��l(i Rear Lot Line
i3a�' ' 4= 4
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Fire Number and Name of Road ��� �1 %r� - �x� �
1. Enter lot dimensions and indicate nortq by arrow. Sig�ar�of O�yne,i,oJ Authorized Agent:
2. Indicate the location and size of the re uested construction ��J.�"
Signature
activities. �L
PrintName: � �uGG S QGlit
3. Also, 1nalCate the locatlon and dlStanCe to the well, The above certifies ihat the listed information and intentions are
true and corted., that all work shall be pedormetl in compliance
septic tank and drainfield, wetland areas, lot lines and to the w�tn tne requ�rements of tne sav+yer counry zonin9 ordinanca
and the laws antl regulations of the State of Wisconsin, and if
Centeillne of the ioad. acting as owner(s)agent, has the permisslon ot the owner(s)to
pedorm the work requested on this applica�ion. The a6ove
personsls here6y give permission for access to the pmperty for
onsite inspecfion.
Permit fee: $ 1 �/5 > ��� <�;=�5
November 4, 2004 _ � 7�
Issue Date Signature of Issui A nt
November 4, 20Q5
50% Rule: Average Road Setback:
Expiiation Date
Office Comments:
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