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, <br /> CI3EC�K OFF i,IST FOR iSSUANCE OF �ERMITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: I (�ti 0 �= o� s� <br /> PID: <br /> DESCRl7'TION OF WORK: R-t--vvwr�e�. + (� e�.�s <br /> ZO�PIG REVIE�V BY: `-- �- �`,� DATE APPROVED: �-{- � � -oe <br /> BUILDTi�IG REVIE�� BY: (Q,�,�,,,..� DATE APPROVED; �-1- i �3-o� <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes _/ No <br /> PLAN REVIE`V Yes �� No SEtiVER CO�tNECI'ION <br /> STATE SURCHARGE Yes �- No WATERCONNECTION <br /> INVESTIGATION FEE Yes No �/ PARK FEE <br /> SAC Yes No � SITEINSPECTTON <br /> Number of SAC Units OTHER (specify) <br /> ----------------------------------------------------------------------------- <br /> Z0�1Ii�TG CH�CK LIST Zoning Discricc: <br /> Fire Department: Post Office: School District: <br /> L,ot Area: Sq.ft. lylo.�o3 Acres 3 •"3� Width 3�o Depth <br /> Survey Submitted: Yes�C _ No Date of Survey: i-2�S'�� <br /> Proposed Setbacks: �►^A"�'�� <br /> � <br /> .�a�t (Lake): 5�,.� 13 R.i�ht Side: 5 3 <br /> �-�SEreet): N L 1�{(� Left Side: �`{•2- <br /> Adjacent Structures: N �v4 Wetland: Asr. I 5 3� <br /> Building Hei��: Def. Hgt, lvo G N�+�.Q. Peak Hgt. — <br /> Lot Covera�e: N � � <br /> Grading: Staff Approval Date: �vo CN�u.0 BY� — Council Approval Date: — <br /> Septic: Scaff Approval Date: ivo c r�y+.'�,c� BY� — <br /> Zonin� File: # � Resolution: # Resolution Date: <br /> Shoreland District: � <br /> Avg. Setback: Bluff Setback: L.ot Covera�e: <br /> EustinQ Proposed <br /> 0 <br /> Hardcover: 0-75' <br /> 75-250' <br /> 2�0-500' <br /> SOQ-1000' <br /> Hardcover Variznce Required: Yes No Dace oE Council Approva!: <br /> RE`L4R.KS (in house): <br /> � <br />