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i C�Ci�O�'F i.IST FOR ISSUANCE OF i'ERMITS <br /> FOR OFFTCE USE ONLY <br /> A.DDRESS ORLEGAL: t3�d E-4��rr �A� �'�� <br /> PID: <br /> DESCR�TTON OF W�RK: Qc-�lc <br /> ------ --- ----_------------------------------- <br /> ZONTi IG REVIEW BY: CS�-c,,._ DA'TE APPROVED: Y- �'-o�' <br /> SLTII�DING REV1��Y BY: DATE APPROVED; Y-Zs-oS-. . <br /> FEES TO BE CHA.RGED: Misc. Fees Calculated By: <br /> PERMIT Yes � No <br /> PLAN REVIE`V � � Yes f No SEWER CO�INEG"ITON <br /> STATE SURCHARGE Yes v No WATERCONNECTION <br /> INVESTIGATION FEE Yes No PARK FEE <br /> SAC Yes No SITEINSPECTION <br /> Number of SAC�Units OTHER (specify) <br /> ZONIi�IG CHE.CK LIST Zoning District: , <br /> Fire Department: Post O�ce: School District: � " <br /> Los Area: Sq.ft. Acres Widch Depth <br /> Survey Submitted: Yes�_ No Date of Survey: �nr � 1=ic,G <br /> Pro osed Setbacks: . . <br /> P <br /> Front(Lake): I bI� '—` Right Side: I�5 ' �' <br /> Rear(Street): 2�to' '�' Left Side: I 00 � "~ <br /> Adjacent Structures: A-rt�ute.a� Wetland: �►1A _ <br /> Buildin�Hei�t: Def. Hgt. —' Peal:Hgc. — <br /> Lot Coveraae: — <br /> Grading: Staff Apgroval Date: —' By: Council Approval Date: ' <br /> Septic: Staff Approval Date: — BY� <br /> Zonin�File: # '— Resolution: # Resolution Date: <br /> Shoreland District: �� <br /> Avg. 5etback: Bluff Setback: I.ot Coverage: <br /> Eustina Proposed <br /> 0 <br /> Hardcover: 0-75' <br /> 75-250' <br /> 250-500' <br /> 500-1000' <br /> Hardcover Variance Required: Yes No Da[e of Council Approval: <br /> RE1�L4RKS (in house): <br /> � <br />