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�HECK OFF i,IST FOR ISSUANCE �F �ER..�'VIITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: ` '� ��9 �� ��I� �In��ca l-�� <br /> PID: <br /> I3ESCRIP`I'�O�T OF WORK: t1,_�����> � <br /> --------_____------------------- <br /> ZO�G REVIE�V BY: � A�.TE APPROVED: t �' r�dirn�j <br /> BUIZDING REVIE'FV BY: DATE APPROVED; io-b -c�� <br /> k`EES TO BE CHARGED:` / Misc. Fees Calculated By: <br /> p�g�T Yes ✓ No <br /> PLAN REVIEtiV Yes � No SE`VER CO�INECTION <br /> STATE SURCHARGE Yes _� No tiVAT�RCONNECTION <br /> INVESTIGATION FEE Yes No —� PARK FEE <br /> SAC Yes No � STTEINSPECTION <br /> Number of SAC Units Q�,�, �3 �L � --rZ r �THER (speci�}r) <br /> -----------------------------------�-----^-t------�-----------�--�i-�-�C�i LY�__�k�.Ca-�:�:LL_i.f--=�.t..���r ZC.'L^f� <br /> � <br /> ZONIi�tG CTIE.CK LIST Zoai.ng District: �Z ' � � . <br /> Fire Department: Post Office: School District: � <br /> �-f � / <br /> Lot Area: Sq.ft. Acres .��SJ Widch � � Depch ,/'�1L� ; -� <br /> Survey Submitted: Yes �� No _� Date of Survey: � Z U `� <br /> ��� I/>•��" f������<��c� `�(z�'�U�j . <br /> Proposed Setbacks: r" ' `U% +- ; <br /> Froat(Lake); �p z. .&a�it S��e: <br /> J-�-p'°� J <br /> Rear(Street): �� L�f�Side: �(� <br /> �?�1— <br /> Adj3C�Ilt .Cr:t1C?�1IZ5; �'j Y} Wetland: V1�r <br /> Buililin� Height: DeE. Hgt. �7 Peal:Ho�• � �O <br /> �, 3 � �_c�� �'��.t�.� -��;,='c"� ��red 4��� r�o� 5bz-w�t <br /> Lot Covera�e: I:��!i � C�lY1�s '�� <br /> �. ���i�'�� ,�-o t�)p�,.�c,R �P�-�e ti. t-o F�r�rg <br /> � 1� Grading: Staff Approval Date: l�-l� '0 '� By: TK- Council Approval Date: ' ��'`�� - <br /> Septic: Staff Approval Dace: �� �Y� �� <br /> � <br /> Zoaing File: �V `'.�� Z Resolutioa: n .%t 7� Resolution Date: (���Z�L� <br /> Shoreland Districc: <br /> Av�. Setback: �x a��1 S B!u;f Setback: I..ot Coverage: <br /> Eciscino Propased <br /> Hardcovec: G-7�' `� <br /> 7�-250' �G <br /> 2�0-500' �Zy <br /> sca-lxo� <br /> ,--- <br /> - `'a:-:z:ce Re�uirzd: Ye� tio V Da�e o:' Co��cu Appr�vai: <br /> H�-eco�e: � <br /> REZ L=�RI�S (in ho us e): �--�r�,�l��' t'���c��� n�.rzs I�+o h�z- � lu�_ i'"-�,ry�--_ <br /> � ��- is ss ��n �'w� , � �, iU <br />