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CHECK OFF LxST k'OR XSSUANCE OF PER�I�IITS <br /> , � FOR OFFICE USE ONLY <br /> - ADDRF�SS OR LEGAL: _ �3 Z oc� I�c��e-�R-+ �'[�2�. b�Z � � <br /> PID: �:, - / 7 �- .� '� ^ / �ac%f . <br /> DFS CRTP'�'I ON OF W ORK: _ . ���>� -�- �}-7- -� --�c-�p e L � <br /> ZO�TiYG REVIE�� BY: � � DAT�APPROVED: /2 -�6 -�"d <br /> BUILDl�i'G REVIEti� BY: � � DATE APP�tOVED: (z- 1 b.•ci� <br /> �'EES TO BE CHA.RGED: • - � Misc. Fees Calculated By: w�M __ <br /> PEFZMIT -Yes ✓ No . <br /> PLAN REV�W Yes ,/ No SEW�t COvi�TECTiON <br /> STATE SL,��H��Gr. Yes �- No �ATER CO�EC'ITON <br /> INVESTIGA'ITON-FEE Yes No PARK FEE <br /> SAC Yes No STTEINSPECZZON <br /> Number of SAC Units �`OTHER (specify) <br /> ZONING C�CK I,IST zoning District: G2-/� �� � ~ <br /> Fire Depart��nt: �,v,�, � % Post Office: Cov�S(��� School District: _C9/LvNc� ' <br /> L.ot Area: Sq.ft._No C��v6�: Acres — tiVidth — Depth — <br /> Survey Submitted: Yes_� No Date of Survey: QN ��c,,� � �-�0_oy$ <br /> Proposed Setbacks: � . <br /> FrearfLa.�Ce): . �3� .=-- . --=`=�t►ghE Side: 30� � _ ,-- <br /> � <br /> &�{Street): � (,� LeR Side: �(� � <br /> Adjacent Structures: I �S ` �' tiVetland: N (,� <br /> Bulldino Height: Def. Hgt. _ (� , (C Peak Hot. <br /> Lot Coverage• — <br /> GradinJ: Stafi Approval Date: -- By; -- Council Approval Date: — <br /> Septic: Staff Approval Dace: — gy; � � . <br /> Zonino Fite: � � � Resolution: � — Resolution Date:� — • <br /> Shoreland Disc.-ict: v�P 5 <br /> Avg. Secback: p�)� BluEf Setback: n/ (� Lot CoveraQe: U. lC . <br /> ' - Existin� Proposed � <br /> Hazdcover: 0-75' <br /> 75-250' ( ' <br /> 250-500' . . �. )� <br /> 500-1OQ0' <br /> Hardcover Vaziance Required: Yes No Z Date of Council Approval: <br /> � <br /> REI�Z.A.RKS ('in house): � � <br /> � - _ . - . <br /> � +,'' . 26 <br /> . ��� . . <br />