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� CgECR OFF LIST FOR ISSIIANCE OF PERMITS <br /> , • � � � FOR OFFICE USE ONLY <br /> ADDRESS OR LE�'�L: I <br /> (��.J C ,S PID: . <br /> Cl ec� ou.�^�- r <br /> D$SCRIPTION OF WORR: ------- --- -------------- <br /> -------------------�--- 3 5,..,_ <br /> ------------------- - - D�� �r�ov$n: <br /> ZONING REVIEW BY: <br /> _ <br /> DATS APPROVED: � � <br /> BIIILDING REVIEW BY: - ---------- ------------- <br /> -------------------- <br /> --------- ------------ <br /> FEES TO BE CHARGED- Misc. Fees Ca�culate By� <br /> PERMIT Yes No <br /> PLAN REVIEW Yes Na SEWER CONNECTION <br /> No WATER CONNECTION <br /> STATE SURCHARGE Yes No pp,RK FEE <br /> Ii�VESTIGATION FEE Yes gITE INSPECTION <br /> SAC Yes No <br /> specif ) <br /> OTHER � Y <br /> Number of SAC Units ---------- <br /> ------- <br /> ----------- -- <br /> LIST Zoning District: <br /> ZONING CHECR � ��� <br /> L� Post Office: � School Dis�.rict: <br /> Fire Department: � !� I <br /> /� L�. �a � Depth: <br /> Lot Area: nL '�' GLGrI'S Width: <br /> ' No� Date of Survey: L � <br /> Survey Submitted: Yes <br /> Proposed Setbacks : r <br /> � '(� Right Side:�D <br /> Front (S�� � <br /> Rear (Street) : <br /> Left Side: ��� � <br /> Adjacent Structures : <br /> Wetland: <br /> Bui�ding Height: Def . xgt. <br /> Peak Hgt. <br /> Lot Coverage: <br /> Avg. Setback: proposed <br /> Exist g <br /> Hardcover: 0-75 ' <br /> 75-250 ' <br /> 250-500 ' <br /> .� <br /> 500-1000 ' <br /> Hardcover Variance Required: Yes No <br /> Date of Council Approval: <br /> Grading: Staff Approval Date: BY� <br /> CounciJ� Approval Date: <br /> Septic: Staff Approval Date: By� <br /> File- # Resol.ution # : Reso�ution Date:�_ <br /> Zoning • <br /> gg�,�p,ggS (in house) : � <br />