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�N �• . �....... <br /> CHECK OFF LIST FOR ISSUAriCE OF PERMTTS ' <br /> FOR OFFICE USE ONLY <br /> �iDDRESS OR LEGr�L: Z25S A C�I�v b d�N w Av <br /> PID: <br /> DESCRIPTZON OF WORK: N EW 2�� <br />' DATE A.PPROVID: 6-/8'S G <br /> ZO�'G ��W BY: • DATE APPROVID: ` -/� -5(. <br /> BUII.DI�TG REVTE'Fi� BY: <br /> FEES TO BE CHAKGED• Misc. Fees Calculated By: <br /> PER'v1IT Yes f• , No <br /> P�N ��w Yes l/' No SEWER CONNECTION <br /> STATE SURCHA.RGE Yes v'' No WATER CONNECTION � <br /> INVESTIGATION FEE Yes No � PARK FEE <br /> SAC Yes No �' STTE INSPECITON <br /> Number of SAC Units OTHER (specify) <br /> ZO�C7 CHECK LIST Zonin.g District: /� �" � Shoreland District: N� <br /> Fire Department: I ' <br /> Post Office: (� School District: ��� <br /> I.o[Area: Sq.ft. 9 g�b9`'� <br /> Acres Z-2� Width 2�3•`/,3!{� Depth �°13 •3�$ <br /> Survey Submitted: Yes �_ No Date of Survey: �/-1�" 5 b I <br /> Pro osed Setbacks: � <br /> p ((,S� '�' Right Side: '7� } <br /> Front (bake�: � <br /> Rear (Sueet): �y 7' � Left Side: °1 � � � <br /> Adjacent Strucnires: �� I� _ We�1�d: /1���' <br /> Building Heighr. Def. Hgt. �`"� Peak Hgt. �� •� <br /> Av;. Setback: Bluff Seiback: Lot Coverage: <br /> Ezisting Proposed <br /> Hardcover: 0-75' <br /> ,�,�' 75-250' <br /> 250-500' <br /> 500-1000' <br /> Hardcover Variance Required: Yes No Dace of Council Approval: <br /> o• Staff A roval Due: lj C� �� By� �`�` o�cil Approval Date: '`—'�' <br /> Gradin�. PP <br /> s f`(� B <br /> Sepdc: Staff Approval Date: Y� <br /> Zoning File: # — Resolution: # � Resoluuon Date: �" <br />� <br /> ' _ ('m house): <br /> i <br />