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CHECK OFF LIST FOR ISSUAI�TCE OF PERtiIITS <br /> _ FOR OFrICE USE ONL.Y � . <br /> ADDRESS OR LEGAL: l �Z c� F' p�C S <br /> PID: <br /> DE.SCRIP'I70N OF ti'YORK: 11.t rvw�e� Ch�ti.c l�ro�a� - <br /> . <br /> ZO��G REVIE�'Y BY: — D�.TE APPROZ'�D: <br /> BUILDIstiTG REY��BY: D?�TE APPROYED: 2 -�- vr . <br /> FEES TO BE CH.4RGED: tiiisc. Fees Calculated By: <br /> PERMIT Yes ✓� No :� <br /> PLAN REVIE�1 Yes ,/ No SEWER CO��iYECTION <br /> STATE SURCHARGE Yes �/ No WATERCO��I�YEC"ITON <br /> I�,'VESTIGATION FEE Yes No _� PA��E <br /> SAC Yes No f SITEINSPECITON <br /> Number of SAC�Units OTHER (specify) <br /> ZOti'7._1tG C�Cb LIST zonin�Disc�.c:: NU C NA/vG�e . <br /> Fire Department: Post Ofnce: School District: - � <br /> L,ot Area: Sq.fr. Acres W dch Depth <br /> Surve;� Sub�itted: Yes No a[e of Survey: <br /> Propased Setbacks: <br /> Froac (L�ke): Ri�`:S;de: <br /> Rear (Screet): I.e`S'.�'=: <br /> Adjacenc Struccures: �Vetlz� : • <br /> Bu�din� Hei�ht: DeE. H�t. Pea`_: t. <br /> Loc Coverage: <br /> Gradin�: Stafi Approval Date: gy: Council Approval Date: <br /> Septic: Stafc Approval Date: By: <br /> Zoain� FIle: fi Resolution: = Resolution Date: . <br /> Shoreland District: <br /> Av�. Secback: B[�_�Setbac{: LOC CO�`�=e' - <br /> E�:;�; Proposed <br /> Hardcover: 0-7�' - <br /> 75-250' � <br /> ti0-500' <br /> Sd0-I000' <br /> Hardcover Vari�ce Required: Yes tio Dace of Cou^cL Aoproval: <br /> gE�IAR�;S (in house): <br /> 7 <br />