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� � Y <br /> , � ` <br /> �HECK OFF i,IST FOR ISSUANCE 4F �ERMITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: 30�c� Gc� R•g � <br /> PID: <br /> DESCR�'TIO�I OF WORK: oo � <br /> ZOVI�TG REVIE�V BY: (M.•C-_� DATE APPROVED: d' S'--�� <br /> BUII�DING RE'VIE�V BY: � DATE APPROVED; G • S-� L <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes ✓ No <br /> PLAN REVIEW �� Yes� No SE`VER CO�]NECTION <br /> STATE SURCHARGE Yes � No WATERCONNECITON <br /> INVESTIGATION FEE Yes No PE1RK FEE <br /> SAC Yes No SITEINSPECTION <br /> Number of SAC�Units OTHER (specify) <br /> ZONI�tG CIi�CK. LIST Zoning District: �. <br /> Fire Department: Post Office: School District: � � <br /> L.ot Area: Sq.ft. Acres Width Depth <br /> Survey Submitted: Yes_ c� No Date of Survey: 5-�6 •O� <br /> Proposed Setbacks: . . <br /> Front(Lake): 13O � Right Side: �2�3 <br /> Rear(Street): 3�G � Left Side: � L•�S <br /> Adjacent Structures: �o � Wetland: Z� ° � '� <br /> Buildin� Heioht: Def. Hgt. N / A Peal:Hgt. '- <br /> Lot Coverage: N I�q <br /> Grading: Staff Approval Date: � .k- By: p�� Council Approval Date: � <br /> Septic: Staff Approval Date: ^! /i° By: <br /> Zoning File: !# �- Resolution: � Resolutioa Date: <br /> Shoreland District: !V� <br /> Av�. Setback: Bluff Setback: I.ot Covera�e: <br /> ExistinQ Proposed <br /> 0 <br /> Hardcover: 0-75' <br /> 75-250' <br /> 2�0-500' <br /> 500-1000' <br /> Hardcover Variance Required: Yes No Da[e of Council Approval: <br /> �E`�L4RKS (in house): <br />