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�HECIK OFF i.IST FOR ISSUANCE OF PERIVfITS <br /> FOR OFFICE USE ONLY <br /> AD�RESS OR LEuAL: %`'f �� S ���%^ �-- I-�ir/ 1 h�� <br /> PTD: <br /> DESCR�'I�ION OF WORK: f)o4���o� /l.C����- �T���/�'t e <br /> ZOVNG REVLE`V BY• _ __ f 1M P � DATE APPROVED: � • r2-U,6 <br /> BULLDING REVIE'FV BY: DATE APPROVED: -�-r 2 �� <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes � No <br /> PLAN REVIEtiV � Yes � No SEtiVER CO�INECTION <br /> STATE SURCHARGE Yes No �VA CONNECTION <br /> INVESTIGATION FEE Yes No -�� FEE <br /> SAC Yes No SITEINSPECTION <br /> Number of SAC�Uruts OTHER (specify) <br /> ------------------- <br /> ZONi��IG CHE.CK LIST Zoning District: �LR.-1� �. <br /> Fire Department: Post Office: Schaol District: � <br /> Lot Area; Sq.ft. 2b�. �3 C Acres G•�R- Widch 6 Z S �` Depch <br /> Survey Submitted: Yes_�_ No Date of Survey: d�• /=� w <br /> Proposed Setbacks: . <br /> F�e�4(Lake): l►�� Right Side: ZI� � <br /> Rear(Street): Z°v� 5�. Lef[Side: 3oa� M�'`� <br /> Ad;acent S�LllCblfeS; � t� ` Wetland: d•k- <br /> Buil�lin� Hei�ht: Def, Hgt. �•�e- Peal:Hgt. �-- <br /> Lot Covera�e: N (/�' <br /> Grading: Staff Apgroval Date: N'U C��� BY� � Council Approval Date: � <br /> Septic: Staff Approval Date: 0 � BY� t,�L <br /> Zoain; File: (#ob-3203 Resolution: � ���� Resolution Date: 6-�Z�ob <br /> Shoreland District: � <br /> Bluff Secback: N i/� L-ot Coverage: /v � <br /> Av�. Setba k: f��� Proposed <br /> Et.isting <br /> Hardcover: 0-7�' Z 10 Z•L <br /> 75-250' ► � —� Z <br /> 2�0-5d0' � o.�0 1 3 <br /> 500-1000' <br /> Hardcover Variance Required: Yes No �_ Dace of Council Approv�l: _ <br /> REl�L4RIkS (in house): <br />