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� CHECK OFF LIST FOR ISSUANCE OF PERI�IITS <br /> FOR OFFICE USE ONLY • . <br /> ADDRESS OR LEGAL: ��I� NO�PTN f}R�'M ��v�S <br /> PID• <br /> DESCRIPTION OF WORK: /V E�,�! �Z-Fs <br /> ZO�"G RE'YIEW BY: � DATE APPROVED: � (-�9 •o� <br /> �. BL7LDL11G REVIE`�BY: � � DATE APPROV�D; �1- r�, -Oo <br /> F'EES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERNIIT Yes t/ No <br /> pI,AN FtEVIEW Yes �/ No SEWF�t CO�YI�'ECITON <br /> STATE SURCHARGE Yes� No �VATERCO1Vi�IEG"ITON <br /> INVESTIGATION FEE Yes No P��E <br /> SAC Yes No SIT�Itii TSPECTION <br /> Number of SAC•Units OTHER(specify) <br /> _________________ - --------- <br /> ZO`�Lti'G CH�CS LIST Zoning Districr. !�2-/A � <br /> Fire Deparcment: m o�N�_ Post Office: �v r•�� � School District: �,��s^r-eN�c A _ <br /> Lot Area: Sq.ft. 115,�g$•37 Acres 2•bb � Width �12?•2S Depth 271 •5 <br /> Survey Submitted: Yes K No Date of Survey: 12�3� • 9 g <br /> Proposed Setbacks: <br /> Front(�a�ta): 1 b3•t Riaht Side: 2�2 � � <br /> Rear(St�eet): S'-1 Left Side: S?� <br /> � <br /> Adjacent Structures: i.r�p� Wedand: G0� �' (�M�N�o�t- ��sem�►�' <br /> Buildin;Height: Def. Hgt. 2�d� Peak Hgt. 35.5 <br /> Lot Coverage: ��A ' <br /> Gradin,: Staff Approval Date: I• �9 -no By: •�� Council Approvzl Date: — • <br /> Septic: Staff Agproval Date: I-�ti- oo By: �•P• <br /> Zonin�File: # � � Resolution: # — Resolution Date: ` �. <br /> Shoreland District: /� <br /> Av�. Setback: Bluff Setback: Lot Co��ra�e: <br /> . Ezistino Progos�d <br /> Hardcover: 0-?5' . <br /> . 75-250' <br /> 250-500' <br /> 500-1Q00' <br /> Hardcover Variance R�quired: Yes No Date of Council Approval: <br /> REI�IARKS('m house): . <br /> 7 <br />