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CHECi�OFF i.IST FOR ISSUANCE �F �ERMITS <br /> ' FOR OFFICE USE ONLY <br /> c�.DDRESS OR LEGAL: �(�S Co Lo(MA C,.�ru� �l <br /> PID: —. <br /> DESCRiP'I'IO�T OF WORK: ��� � -n o�--� o�-e� C��c�-e <br /> ------------ - _--�____--------------------- ------------------------------�--_----- <br /> ZO�tG REVIEW BY: C�_ DATE APPROVED: 3-�� -Oto <br /> SUII�DING REVIE`Y BY: DATE APPROVED; 3 -�S� . <br /> FEES TO BE CI3ARGED: Misc. Fees Calculated By: <br /> PERMIT Yes �/ No <br /> PLAN REVIEW � Yes c/ No SEWER CONNECTTON <br /> STATE SURCHARGE Yes ✓ No WATER CONNECTION <br /> INVESTIGATION FEE Yes No �/' PARK FEE <br /> SAC Yes No � STTEINSPECTION <br /> Number of SAC�Units OTHER (specify) <br /> ZOYING CHE.CK LIST Zoning Districr. /��4'-/(j _ . <br /> Fire Department: Post OfFice: School District: � <br /> 9c�c� s�►� <br /> Lot Area: Sq.ft. �2,5� `I Acres � 24 Widch �3 Q �s�s-�.�c�c Depth <br /> Survey Submitted: Yes 1— No Date of Survey: oc�r �°�,°S <br /> Proposed Setbacks: <br /> Front(Lake): 1 l7� � Right Side: �� •� <br /> Rear(Sueet): Z � Left Side: 11• 'L <br /> Adjacent Structures: y�;T�►c�1-t�� Wetland: N I � <br /> Buildin� Height: Def. Hgt. p•1� Peal:Hgt. — <br /> Lot Coverage: /t!a c I-h�r�� <br /> Grading: Staff Approval Date: niv G��t��P By: Council Approval Date: ' <br /> Septic: Scaff Approval Date: ^n/ (/� By: <br /> Zoaing File: �# 06-3��`� Resolution: # Resolution Date: 2- �g-O� <br /> Shoreland District: u �E5 <br /> Avg. Setba� r 1� Bluff Setback: N�/� L.ot Coverage: <br /> Eusti.ng Proposed <br /> Hardcover: 0-75' 9.S `�•3 <br /> 75-250' SL:! sy . � <br /> 2�0-500' <br /> 500-1000' <br /> Hazdcover Variance Required: Yes � No Date of Council Approval: Z-130e <br /> REI�iARKS (in house): <br /> � <br />