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CHECK OFF LIST FOR ISSUANCE OF PERMITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: 3�S �'vssex ('i4�s�'� <br /> PID:' <br /> �ESCRIPTION OF WORK: ��c� �.=3 <br /> ZO�TG REVIEW BY• DATE APPROVED: �v-�o -a l <br /> BUII..DING REVIEW B : DATE APPROYED; /0•3�-�t <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERNIIT Yes _�� No <br /> PLAN REVIEW Yes �/' No SEVVER CONNECTION <br /> STATE SURCHARGE Yes _� No WATERCONNECTTON <br /> INVESTIGATION FEE Yes No PARK FEE <br /> SAC Yes No STTEINSPECTION <br /> Number of SAC�Units OTHER (specify) <br /> ZONING CH�CK LIST Zoning District: ,�-/Q . <br /> Fire Department: Post O�ce: School District: � <br /> Lot Area: Sq�.ft. Acres 2� Width �(i/Zc��c�-i� Depth <br /> Survey Submitted: Yes�_ No Date of Survey: �o -Z Y-01 <br /> Proposed Setbacks: <br /> Front(Lake): SZ� � Right Side: 23�6� <br /> Reaz(Sueet): ,��.6 6� Left Side: I 2�5� <br /> Adjacent Structures: /t1 (/� Wetland: N /✓� <br /> Building Height: Def. Hgt. 'jc� Peak Hgt. _� `(3•?�_, <br /> Lot Coverage: /V I v°t <br /> Grading: Staff Approval Date: ��-3 v-n� By: o�'� - Council Approval Date: <br /> Septic: Staff Approval Date: « '�0 �01 By; �e- <br /> Zoning File: # --- Resolution: # Resolution Date: <br /> Shoreland District: N 0 <br /> Avg. Setback: Bluff Setback: L.ot Coverage: <br /> Existing Proposed <br /> Hazdcover: 0-75' <br /> 75-250' <br /> 250-500' <br /> 500-1000' <br /> Hazdcover Variance Required: Yes No Date of Council Approval: <br /> REMARKS(in house): <br /> 7 <br />