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' - CHEC�: OFF LIST F�RE USE pNL OF PERtiIITS <br /> FOR O <br /> :�DDRESS ORLEG:�L: 165o ivorzn+ FA�pID' <br /> DESCFtIPTIO\ OF «�OR�� N��-' '�5' <br /> - ----------------------- cT C�� DATE APPROVED: � - z t-�i 5 <br /> ZOtiZti G REVIE�V BY: DATE APPROVED: �r-�!-s s <br /> BL�II.DL\G RE�ZEtiV BY: <br /> ---------- ---------- � <br /> FEES TO BE CH.�,RGED: <br /> l�iisc. Fees Calculated By: <br /> PERti1IT YzS � �o <br /> tir SE`�ER CON�i tECTION <br /> PL:��1 REVIE��1 �"es � 1 0 <br /> WATER CO�'EC170N <br /> ST:�TE SURCH?�RGE Z'zS �' �0 �-- pARK FEE <br /> Iv VESTIG:�TIO�+ FEE YzS �o <br /> SAC Yzs �to �` SITE 1NSPECTION <br /> OTHER (specify) <br /> Number of S�C Lnics _______ ____�M___ <br /> --------------- <br /> -------------- �' <br /> ZO\L\G CHECI� LIST Zonin� Discrict: L/Z-//f <br /> Shoreland Distnct : <br /> �� (,C, Scnool Discrict: ��'"fl <br /> Fire Departmeat: Post Office: <br /> Lo�Are�: Sa.fr. 9�__ _ <br /> ?.cres 2 � Nidth �I��1✓�2 Depch <br /> Survev Suorni�ted: Yes X <br /> ,�To Date of Survey: � "LS "45 <br /> Proposed Sztbac!cs: (� <br /> Frer_t lLai:e)= 7`�'`t Ri�n[ Side: C��•`� Z �' <br /> i <br /> Re.:r (Sc.eet): �Do -'— Leit Side: I 1 Z•�Y.` � <br /> .-�djacent Scruccures: N�/� Wetland: 3 �•5 <br /> o � ' <br /> Buildin� Height: Def. H�t. Z Z•} Peak H��. 3 <br /> ,�,vQ. Setback: /��� <br /> Bluff Se.back: i✓�/a- Lo[ Coverage: /`�/�' <br /> E�iscin� Proposed <br /> Hy.rdcover: 0-�5' <br /> 75-250' <br /> 350-�00' � �� <br /> 500-1000' <br /> Hardcover Variance Required: Yes __ No P� Dace of Council Approval: _,__ <br /> Grading: Start �oproval Dace: 9-2(- `I5 <br /> By: -�Council :'.pproval Date: <br /> Sepcic: Starf .�pproval Dace: B"3�'�S By: �.�'`� <br /> � <br /> Zonin� Fiie: _�_ <br /> Resolution: r � Resoiution Date: <br /> ��,�g� (in house): <br /> 26 <br />