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� , CHECI� OFF LIST FOR ISSUA�.�TCE OF PERtifITS <br /> _ FOR OFFICE USE Oi�1"L.Y . � . <br /> p,DDRESS ORLEG.4L: I �c� `(��b �SC�r�✓� <br /> PID: <br /> DES CRIPT'ION OF�ORK: � ,�}�-�o o.� �x �s�^�6 �.�-r�` <br /> , <br /> ZOrZtiG REV��'BY: D�TE APPROV�D: 6�i z-�� <br /> BUII��3 .�i'G REVIE�BY: � D�.TE APPROV�D: ��, - �z =v� <br /> F'EES TO BE Cg4RGED: Niisc. Fees Calculated By: <br /> pEgMi'I' Yes ,/' No :� <br /> PLAN REVIEW Yes � No SEWER C0�INECTION <br /> STATE SURCHARGE Yes � No �VATERCONNECTION <br /> I�i,'VESTIG�TION FEE Yes No PARK FEE <br /> SAC Yes No SITEINSPECITON <br /> Number of SAC�Units OTHER (specify) <br /> ZO��I:1IG CH�CB LIST Zoni.n�Distzicc: /� G. . <br /> Fire Department: Post Ofuce: School Dis�ict: • � • <br /> Lot Area: Sq.fr. Acres � Width Depch <br /> Survev Sub�'tted: Yes No Date of Survey: <br /> Propased Secbac!<s: <br /> F.oet (Lake): Ri;ht Side: � <br /> Rear (Screet): Left Side: <br /> Adjaceat S..�ctures: �Vetl d: • <br /> Buildin� Hei�c: D�:. H�t. Pe�� �t. <br /> Lot Covera��: <br /> Gradin�: Scafr App:::v�l Date: gy Council Approval Date: <br /> Septir. Stafr Appro•,•aI Date: By <br /> Zo��File: R Resolu�ion: � Resolutioa Date: _ . <br /> Shoreland District: <br /> Av�. Se[oac'<: Blufi Secback: I.oeCocera�e: <br /> E���? Proposed <br /> H�dcover: 0-7�' <br /> 7�-250' - <br /> ti0-SQO' <br /> SOa-I000' - <br /> Hardcove:Variance Required: Yes No Dat� of Council Aoproval: _____.__ <br /> REI�LA.R3�S (in hous e): �-�,�r� �� c,cJ� � � rN � � 1 a`� I�e,G(� <br /> � <br /> 7 <br />