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CHECK OFF LIST FOR ISSUANCE OF PERIVIITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: T o N 6A A� <br /> PID: <br /> DESCRIPTION OF WORK: D�:U►�- <br /> ----------------------------- <br /> ZOtVI1VGREVIE tVBY: DATEAPPROVED: q-0•04— <br /> BUILDING REVIEW BY: DATEAPPR06'ED: q- 6 -05-- <br /> ----------------------------------------------------------------- <br /> FEES TO BE CHARGED: hfisc. Fees Calculated By: <br /> PERNfIT Yes ✓ No <br /> PLAN REVIEW Yes !/' No SEYVER CONtVECTIOtV <br /> STATE SURCHARGE Yes No WATER COi tNECTIOtV <br /> INVESTIGATION FEE Yes vo PARK FEE <br /> SAC Yes tYo SITE INSPECTION <br /> Number of SAC Units OTHER (specify) <br /> -------------------------------------------------------------- ---- <br /> ZONING CHECK LIST Zorting Disb•ict: <br /> Fire Department: Post Office: School District: _.. <br /> Lot Area: Sq.ft, Acres Width Depth <br /> Survey Submitted: Yes—e — No Date of Survey: -7--7 -0 3 <br /> Proposed Setbacks: y p. <br /> Front(Lake): 1 S Riglit Side: <br /> Rear(Street): 4m y2 Left Side: <br /> Adjacent Structures: 47114""E-2 6Uetland: N/19 <br /> Building Height: Def. Hgt. AIIA Peak Hgt. <br /> Lot Coverage: <br /> Grading: Staff Approval Date: Al /G By Council Approval Date: <br /> Septic: Staff Approval Date: All if By: <br /> Zoning File: # -- Resolution: # Resolution Date: <br /> Shoreland District: v t�5 <br /> Avg.Setback: /V 4 Bluff Setback: 1✓/,- Lot Coverage: N��- <br /> Existing Proposed <br /> Hardcover: 0-75' 25• S <br /> 150-500' ---�- <br /> 500-1000' <br /> Hardcover Variance Required: Yes Noye- Date of Council Approval: _ <br /> REMARKS(in hotcse): <br /> 31 �° <br />