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* CHECK OFF LIST FOR ISSUANCE OF PERVIITS <br /> FOR OFFICE USE ONI.Y • <br /> ADDRESS OR LEGAL: �755 �OPD�. 1/i E bJ l� <br /> Pm• 33 �l - a3- �3 oar7 <br /> DESCRIPTION OF WORK: C2E�I"� 3Fnk^-s <br /> ZOr�'G RE�'IE�V BY: � � � DATEAPPROVED: y�(�''00 <br /> BLZLDLVG REVIEtiV BY: N�AT � DATE�PROVEA; � ,¢ � <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> pE�y�T Yes No <br /> PLAN REV�� Yes No SEtiVER CO�'ECIZON <br /> STATE SURCHARGE Yes No �VATERCON�v'EC'IION <br /> INVESTIGATION FEE Yes No P��E <br /> SAC Yes No SITEI�SPECTION <br /> Number of SAC�Units OTHER(specify) <br /> ZO�Z\G CII�CK LIST Zoning Districr. I� (� ' J .� �. <br /> Fire Departmenc: C�� Post Office: L �--- School DSLLict: �� 7 g� <br /> �J � <br /> Lot Area: Sq.fc. �00 7 Acres G . � � Width �30 Depth �3� <br /> Survey Submitted: Yes� No____r_ Date of Survey: �'a�'�`�� <br /> Proposed Setbacks: <br /> Fron[(La.�ce): N�k Ri�t Side: � ��A' - . <br /> . � <br /> Rear (Sueet): /J��4- Left Side: <br /> Adjacent Structures: — �Vetland: — <br /> Building HeiQhc: Def. Hgt. —' Pe�k Hgt. " <br /> Lo[Co�•era;e: � ' <br /> Gra��n�: Stafi Approval Date: By: Council Appro�zl Date: <br /> Septic: Staff Aporoval Date: By: <br /> Zonin�File: � Resolution: � Resolutioa Date: <br /> Shoreland District: <br /> Av�. Setback: Bluff Setback: I-°�C°�'ra�e' . <br /> . Ezistmo Progosed <br /> Hardcover: 0-7�' <br /> 75-2�0' <br /> 2�0-500' <br /> SOa-1000' <br /> Hardcover Variance R�quired: Yes No Date of Counci Approval: - <br /> RE1�L4RFiS ('in house): <br /> 7 <br />