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rA'RCg Ogg LI9�T FOR ISSIIANCE OF PERMITS <br /> � ' ' FOR OFFICE USE ONLY <br /> AnD�ss oR zEc,�: 'YS�0 /V��TI•{ A��`►�( d/�f��PID: <br /> DBSCRIPTION OF WORK: n�E Z'7 ------------------ <br /> -----------------------�------------�--DATE APPROVED:---S�Z 2-cl�S' <br /> ZONING REVIEW BY: <br /> �,N,,,.` DATE APPROVED: J -2Z-9S' <br /> BIIILDING REVILfF7 BY: � -------------------------------- <br /> --------------------- <br /> -------------------- <br /> FEES TO BE CHARGED: Misc. Fees Ca].culate By: <br /> PERMIT Yes �No <br /> PLAN REVIEW Yes �No SEWER CONNECTION <br /> � No WATER CONNECTION <br /> STATE SURCHARGE Ye5 pp,gg FEE <br /> INVESTIGATION FEE YeS NO-� SITE INSPECTION <br /> SAC YeS N� � OTHER (specify) <br /> Number of SAC IInits --�-,------------ <br /> ---------- LIST -----------------Zoning District: 1'�-�+-�' A <br /> ZONING CHECR <br /> Fire Department: ✓Ltr���` _ <br /> Post Office• W�A�^� School District: 1.��� <br /> Lot Area: 5 �{4 �'�� _ Width: 2� <br /> � Depth: gS`�` <br /> Survey Submitted: Yes�, <br /> No Date of Survey: 2'�'� <br /> Proposed Setbacks: Right Side: l(oS� � � <br /> Front (Lake) : /v�B�__- <br /> Rear (Street) : - 5'� <br /> ' f- Left Side: 9ar i= `"� <br /> Adjacent Structures: �*�'�� <br /> Wetland: /t��1�"" <br /> Hei ht: Def. Hgt. t� .U P ak Hgt. � � <br /> Building g <br /> Lot Cov rage: <br /> Avg. Setback: rop sed <br /> Existi g <br /> Hardcover: 0-75 ' <br /> 75-250 ' <br /> 250-500 ' <br /> 500-1000 ' <br /> Hardcover Variance Re uired: Y s N <br /> ate of Cou cil Approval: <br /> Grading: Staff Appro aI. Date: By' Counci APP <br /> roval Date: <br /> Septic: Staff Appro al Date: By�---- <br /> Zoning <br /> File:# Resolu 'on Reso ution Date: <br /> gg�p�ggS (in house) : ' <br />