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CHECK OFF LXST FOR XSSUANCE Ok' PER�I�ITS <br /> � FOR OFFICE USE ONLY <br /> ADDRF�SS OR LEGA.L: _ /S 3 S l�o t-� 5 . Qo,.,v� 12� . <br /> � �'IID: <br /> DFSCRIPTION OF ti'YORb'.: _ .Z�1Z�►2� a�2.._ (�vSy�,�-� . <br /> ZOti' .3�i tG REV�ti� BY: c� ^ � M DAT'E APPROVED: Z -�'� `� �' �- <br /> BITU,DPi IG REVIE�� BY: � � DATE APP�20VED: Z ��3- g g <br /> FEES TO BE CHARGED: • � Misc. Fees Calculated By: N <br /> PERNIIT _ _Yes ✓' No ' <br /> PLAN REV�W Yes ✓' No SEW�COYNECTION <br /> STATE SUR`HARGr, Yes ✓ No ��ATHR CONNECTION <br /> INVESTIGAZ'ION-FEE Yes No PARK FEE <br /> SAC Yes No SITEINSPECTTON <br /> Nu�ber of SAC Units � O'I'HER (specify) <br /> ZONING CHECK 1.IST zoning Districc: �t/U C/���L - '-' ----__ . ___ <br /> Fire Deparm�ent: Post Ofrice: School District: ' <br /> Lot Area: Sq.fr. Acres �Vidth Depth <br /> Survey Subm�itted: Yes No Date of Survey: <br /> Proposed Setbacks: . <br /> Front (La.ke): Righ[Si • -----_ . _ .. ..__;. __- <br /> Rear (Street): Left Side <br /> . Adjacent Structures: ti etland: <br /> Building Height: Def. Hgt. P a.k Hot. <br /> Lot Coverage: <br /> Gradi.n�: Stafi Approval Date: - y; Council Approval Date: <br /> Septic: Staff Approval Date: y• • � . <br /> Zoning File: � - Resolution: � Resolution Date:� • <br /> Shoreland Dis�-ict: � <br /> Avg. Setback: Bluff Setback Lot Coverage: <br /> � ' Eusting Proposed <br /> Hardcover: 0-75' <br /> 75-250' . . � ' <br /> 250-500' . • <br /> SQO-1000' <br /> Hardcover Variance Required: Yes No Date of Council Approval: <br /> � <br /> REI�Z�.RKS ('in house): � <br /> � - . • . <br /> , • �t� .26 . <br />