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r <br /> CHECK OFF LIST FOR ISSUANCE OF PERMITS <br /> FOR OFFICE USE ONLY- <br /> ADDRESS OR LEGAL: '17 3 1 <br /> © ;A <br /> FED: <br /> DESCRIPTION OF WORK: _ - -- <br /> - <br /> ______------ PROVED: D <br /> --- GRE W BY: --------- ----`%v DATE AP _ <br /> �ON�I VIE DATE <br /> -~ APPROVED: <br /> B <br /> UILDING REVIEW BY: •�.-- <br /> _ ------------------------ <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PER1�TYes ,/ No <br /> PLAN REVIEW Yes Yes No SEWER CONNECTION <br /> Yes --�� No _ WATERCONNECTION <br /> STATE SURCHARGE PSI{ FEE <br /> INVESTIGATION FEE Yes No p <br /> SAC Yes No SITEINSPECTION <br /> �' THER (specify) <br /> Number of SAC-Units ----- ---------- ��a,s <br /> ------ - - - �cch r l a -� <br /> -- t.�rtc,0 �. � ooy . pd <br /> 7,ON11NG CHECK LIST Zaruna District: P� 1 <br /> Post Office: School District: <br /> Fire Department: <br /> Width 0 1 Depth <br /> Lot Area: Sq.ft. ( � Acres r <br /> Survey Submitted, Yes <br /> No Date of Survey: , <br /> Proposed Setbacks.. / <br /> Front(Lake): , Ri�Side. <br /> Rear(Street): Ot Side: I� <br /> // <br /> Adjacent St,„rruIeSI �/ Wetland: <br /> Building Height: Def, Hat. Peal`Hgt. <br /> Lot Coverage: D <br /> T K Council Approval Date: <br /> GradLna: Staff Approval Date: 6 •t rB - C�� By-, -L-- <br /> Septic: Staff Approval Date. W) By: LJ <br /> 7ouina He: � 'J�� Resolution: R______ Resolution Date: <br /> Shoreland District: V P5 /f�� <br /> Buff Setback: v I Lot Coverage: <br /> AvQ. SetbProposed, <br /> 1✓ustino <br /> Hardcover: 0-75' <br /> 75-250' <br /> 2-'J-DGS <br />