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�HECK OFF i�IST FOR iSSUANCE OF PER.i.'VIITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS ORLEGAL: I 93"i rAG�RNE55 Po�Nr ►��o <br /> PI17: <br /> DESCRIPI,ION OF WORK: �6�t.c:�S wi�o� �- �Pc� .�r2 <br /> ZO�G REVIE`V BY: r-- ,� AATE APPROVED: �g,5-o� <br /> BUII�DI�IG REVIE�V BY: DATE APPROVED: �zs-o� <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes � No <br /> PLAN REVIE�V � Yes .� No SEtiVER CONNECTION <br /> STATE SURCHARGE Yes -� No tiVATERCONNECTTON <br /> INVESTIGATION FEE Yes No _� PARK FEE <br /> SAC Yes No __� SITEINSPECTTON <br /> Number of SAC�Uruts OTHER (specify) <br /> ZO�G CIiE.CK LIST Zoning District: , <br /> Fire Department: Post Office: School District: � <br /> L,ot Area: Sq.ft. Acres Widch Dep[h <br /> Survey Submitted: Yes _ c No Date of Survey: D� t'� �.� <br /> Proposed Setbacks: <br /> Froat (Lake): ght Side: <br /> Rear (Stree[): Left Side: <br /> Adjaceat Structures: Wetland: <br /> Building Hei�t: Def. Hgt, Peak.Hgt. <br /> Lot Coverage: <br /> Grading: Staff Approval Date: By: Council Approval Date: ' <br /> Septic: Staff Approval Date: BY: <br /> Zonin� File: � Resolution: Resolution Date: <br /> Shoreland Districc: <br /> Av�. Setback: B ff Secback: Lot Coverage: <br /> Eu tina Propvsed <br /> 0 <br /> Hardcover: 0-75' <br /> 7�-250' <br /> 2�0-560' <br /> 500-1000' <br /> Ha:dcover Va�ia�ce Required: Yes `!o Da!e oE Council Approvz: <br /> �E`L�R�iS (in house): u��nrpoW �,.�e��- o�-t5 r��� (lx�i� i,�c.r s� � 6Ack - �euc <br /> 5�x,��. is i� r � ,.�. �,. ,.�,,,_ �a-,�,�� (�l Q��IA�� �o� <br /> Y�N �r.�,��;;;� �- � . <br /> (��u)1t.�3 �� 3 1�4ri� t,^� /4T !�0 7'T-�1/�n 0 F= .S TY!�/l5 -SD .S i�4 r�_ /�'/CG� /L6"t v��it'P <br /> -}-a ��o N�1�iJ �' �n.ow.. C.o� C.�M� <br />