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� . • � CHECh' OFF LIST FOR ISSUA!�CE OF PER�tifXTS <br /> _ FOR OFFICE USE ONL.Y . � . <br /> ADDRESSORLEGAL: 1�-t043 (3Ac.c�crz P�2K r��'^0 <br /> PTD: <br /> DES CRLPTION OF ti'YORK: 2�n,� 5�2ti Jk�0►n �•J - <br /> ' <br /> ZOr�'G REY�ti�%BY: D�TE APPROYED: � - � t-o� <br /> BUILD .�i'G REVIE'SV BY: _ D�TE A.PPR4YID: � - i � - n� <br /> FEES TO BE CIiARGED: Niisc. Fees Calculated By: <br /> pERMIT Yes c/ No .: <br /> pl,,p,N REVIEW Yes �/' No SES�ER CO�INECT'ION <br /> STATE SURCHARGE Yes ✓ No ��IATERCONNECI'ION <br /> I�,'VESTTGATION FEE Yes No PARK FEE <br /> SAC Yes No SITEINSPECTION <br /> Number of SAC�Units OTHER (specify) <br /> Zp�iL1IG CHE�CK LTST Zonin� Districc: . <br /> N�o ' � <br /> Fire Department: Post Ofuce: Sc�Qol District: • • <br /> � <br /> Lo[Area: Sq.fr. Acres � Width Depch <br /> Surve,� Sub.�.itted: Yes�_ No Date of Survey: e�i✓ i=��3 <br /> Proposed Setbacks'. <br /> Front (Lake): t 2� � Ri?ht Side: � (I � <br /> Rear (Screet): 95' Left Side: ►O' <br /> Adjacent Structures: t� ( V�. �Vetland: N I�A • <br /> Buildin� Hei�ht: Def. H�t. ta 1<- Peak H�t. � •�< <br /> I,o[ Covera�e: N u C u-�b�v� <br /> Gradin�: Stafc Approvzl Date: gy; Council Approval Date: <br /> �,1°� Septic: Staff Approval Da�e: By• <br /> �� . <br /> G� Zoaing File: � Resolution: � Resolucion Date: . <br /> Shoreland District: u�py <br /> Av�. Secback: Bluft Setback: LotCo�'era�e: <br /> E���j Proposed <br /> Hardcover: 0-7�' <br /> 7�-250' - <br /> ti0-500' <br /> 500-1000' <br /> Hardcover Variance Required: Yes No Date of Council Aoproval: <br /> REI�iA_RIiS (in hause): <br /> 7 <br />