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r . <br /> �HEC]K OFF i�IST FOR ISSUANCE OF �ERMITS <br /> FOR OFFICE USE ONL�.'� j <br /> A,DDRESS OR LEGAL: ��0� � ?�(J ��/.��S �/� � �C�A C'� <br /> Pzn• �L �[( P� - 23 -yZ - nc�o5 - <br /> DESCRIPI'ION OF WORK: ,�u�!x-�� <br /> --- --------- � -------------------------------------------------------------- <br /> ZOYI,TG REVIE'FV BY: DAT'E APPROYED: -I -o c,a <br /> � � DATE APPROVED; S :3 <br /> �UII.�DING REVIE��Y BY: . � � <br /> �'EES TO BE CHA.RGED: Misc. Fees Calculated By: ' <br /> pEg�T Yes � No <br /> PLAN REVIE`V �� Yes -� No SE��ER CO�iNECTION <br /> STATE SURCHARGE Yes � No `VATERCONNECTION <br /> INVESTIGATION FEE Yes No —� PARK FEE <br /> SAC Yes No �,` ' ' SITEINSPECTION <br /> Number of SAC�Units ���, OTHER (specify) <br /> ----------------------��-Io�-------------------� � <br /> ---- CIiT.�CK LIST -------g----------------- , � � {�bpe.fc l o <br /> ZONI�IG zonin District: . <br /> Fire Department: �--�-- Post,OfFice: �-�- School District: •27� � <br /> L,ot Area: Sq.ft. Acres <br /> � Width _��� Depch 3 Z-� 37 . (po <br /> Survey Submitted; Yes � No Date of Survey: 7 O O �O <br /> Proposed Setbacks: i'Ic�.d('h � � �Y��, �,;r b,�rc,k 1e�4� <br /> Front(.�.�j: ZOC� F�Side: 54 _ ��,.J' �''`'I , <br /> G �N'� � <br /> Rear(&rezt): � ` �. Lge€t.Side: ��— <br /> r ' ►'I�r ��eSS �� <br /> Ad;acent St:uctures: Wetland: 5 <br /> , <br /> Dv4- l o�- �� Q I�� <br /> Builclin� Hei�t: Def. Hgt. 2� Peal:Hgt. Z S _ <br /> � ���w�i <br /> Lot Coveraje: k`�� <br /> Grading: Staff Approval Date: g ' 3 "� � By: C T"��Quncii Approval Date: ' <br /> Septic: 5taff Approval Date: �'� � �vv �y; � � � , - ' <br /> Zoain� File: ��_ Resolutioa: � _ Resolution Date: <br /> Shoreland Districc: IV� <br /> Av�. Setback: Bluff Setback: LocCovera?e: <br /> Ecistin� Proposed <br /> 0 <br /> Hardcover: 0-75' <br /> 75-250' <br /> 2�0-500' <br /> 500-1000' <br /> Ha.rdcover Vari2nce Required: Yes �o Da�e o�Co�ncil Approv�.: <br /> R.E`L4R�iS ('Lnhouse): �S(� Q� W � J'rB� ��e.�} ZO� <br /> 0 <br /> ``s " <br />