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CHECK OFF i,IST FOR ISSUANCE OF PERNIITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: �jr 6a F D x sT _ <br /> PID: -- . , ' <br /> DESCR�`TION OF WORK: (�,�p , -�t o r�1 <br /> ZO�tI1�1G REVIE`V BY: DATE APPROVED: Z- �b- o� <br /> BUII�DING REVIEtiV BY: DAT'E APPROVED: 2-► � -� � <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes ✓� No <br /> PLAN REVIE`V Yes f No SE�VER CO�INECTION <br /> STATE SURCHARGE Yes �/ No WATERCONNECTION <br /> INVESTIGATION FEE Yes No ,/ PARK FEE <br /> SAC Yes No �/ SITEINSPECTION <br /> Number of SAC Units OTHER (specify) <br /> ----------------------------------_—_------------------------------------------------------------------------ <br /> ZO��tG CI�CK LIST Zoning District: <br /> Fire Department: Post Office: School District: <br /> Lot Area: Sq.ft. 50,337• �3 Acres (,t5 Widch , z,o o.S Depth ZS � • o '� <br /> Survey Submitted: Yes � rIo Date of Survey: `a '� S-0 S <br /> Proposed Setbacks: <br /> Front (Lake): ��Z Right Side: �(� <br /> Rear (Street): 5���( Left Side: 7 0 <br /> Adjaceot Stcuctures: 3b` Wetland: A1 I A <br /> Buildin� HPioh[: Def. Hgt. C9 .1c- Peal:Hgt. — <br /> Lot Covera�e: 7,I °�� <br /> Gcading: Scaff Approval Date: �- I( -U ! By: � Council Approval Date: <br /> Septic: Staff Approval Date: �i-�'�s By: W •(� . <br /> Zoning File: f# — Resolution: # — Resolution Date: <br /> Shoreland Distric[: /L� <br /> Av;. Setback: Bluff Setback: I.ot Coverage: <br /> E�isting Proposed <br /> Hardcover: 0-75' <br /> 7�-250' <br /> 2�0-500' <br /> 500-1000' <br /> Hardcover Variance Required: Yes No Da:� of Council Approval: <br /> �E��LARKS (in house): <br /> � <br />