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Type Amount Date Paid Receipt # Permit No: Land Use $ Land Use $ Date Issued: Cond. Use $ A-T-F Double $ Zone Chg No: Vendor # Variance No: Revised 03/08/2022 DOUGLAS COUNTY PLANNING, ZONING & LAND INFORMATION OFFICE 1313 BELKNAP STREET, ROOM 206, SUPERIOR, WI 54880 715 – 395-1380 / FAX 715 – 395-7643 APPLICATION FOR PERMIT: LAND-USE CONDITIONAL-USE APPLICATION WILL NOT BE PROCESSED WITHOUT SIGNATURE & DATE ON THIS PAGE. ZC TO WHOM IT MAY CONCERN: The undersigned hereby applies for a permit to do work herein described in this application. The undersigned agrees that all work will be done in accordance with the Douglas County Zoning, Shoreland Zoning, Subdivision Control, Floodplain Ordinances and with all laws of the State of Wisconsin applicable to said premises. DO NOT start any construction until this office has issued a permit. Failure to obtain the necessary permits will result in a double permit fee and/or citation. CONDITIONAL-USE PERMIT APPLICATIONS: PLEASE CONTACT TOWN CLERK - APPLICATIONS REQUIRE REVIEW BY YOUR TOWN BOARD PRIOR TO SCHEDULED ZONING COMMITTEE PUBLIC HEARING Property Owner’s Name: Mailing Address: City, State, Zip Telephone: E-mail Address: PROPERTY DESCRIPTION: Information must be complete and accurate. If applicable state lot number, block number, subdivision name, government lot number, quarter sections, etc. (Note: This may be copied from your tax notice or deed. Tax Parcel Section Town N Range W Town of: Parcel Acreage or Size: Property Address: Legal Description: Name of Adjacent Lake or Stream: Wetlands: Yes No Zone District______ Type of construction: (accessory building, dwelling, addition to seasonal dwelling, alteration to accessory building, relocate structure) Proposed Use: (year-round or seasonal dwelling, storage, commercial use, change use of structure) Width Length Area (sq ft) Height Stories # Bedrooms # Occupants Est Cost - $ Dwelling Accessory Bldg Please stake building site prior to submitting this application. Site Staked - Yes Has any portion of the project been started? Yes No Sanitary Permit By signing this application, I give my/our permission to allow a site inspection to be made of the site by Zoning staff and allow photographs to be taken if necessary. I hereby agree to terms and conditions on following site sketch page. Property Owner Signature: Printed Property Owner Name: Agent’s Name, Address & Phone: SIGN ---PAGE BREAK--- * SITE SKETCH * SCALE: 1 Block = feet If drawing is not to scale show all dimensions (See Below for Requirements) Site Sketch to Include: Road/Highway Name Driveway Existing Structures (labeled) Well (Old/New) New Structure with dimensions - (YR/Seasonal Dwelling - Include floorplan of all levels) Sanitary/Privy (old/new) Measurements from Lot Lines, Center Line of Road, and Ordinary High Water Mark (Lake, River or Stream) You are responsible for complying with State and Federal laws concerning construction near or on wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to identify. Failure to comply may result in removal or modification of construction that violates the law or other penalties or costs. For more information, visit the Department of Natural Resources wetlands identification page or contact a Department of Natural Resources Service Center. Additional responsibilities for owners of projects disturbing one or more acre(s) of soil I understand that this project is subject to regulations regarding erosion control and storm water management and I will comply with those standards. For more information, visit the Department of Natural Resources or contact a Department of Natural Resources Service Center. It is the property owner’s responsibility to know the location of their lot lines to ensure setback requirements are met.