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CHECK OFF LIST FOR ISSUANCE OF PERMITS <br /> FOR OFFICE USE ONLY <br /> ADDRESS OR LEGAL: ZS- 012-0<)-0 OrEa;.M: �JPID: <br /> DESCRIPTION OF WORK: Q h.„Q10% i Pop ci-4 , <br /> ZONING REVIEW BY: NIS . -..._ DATE `APPROVED: <br /> BIIILDING REVIEW BY: <br /> DATE APPROVED: <br /> � <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes .�No <br /> PLAN REVIEWYes • ---"-No SEWER CONNECTION <br /> STATE SURCHARGE Yes —No WATER CONNECTION <br /> INVESTIGATION FEE Yes No PARK FEE <br /> SAC Yes No INSPECTION <br /> Number of SAC Units OTHER (specify) <br /> ZONING CHECK LIST Z. ing District: <br /> Fire Depar sent: Post .ff' ce: Sdhool District: <br /> Lot Area: Width: D-pth <br /> Survey Submit ed: Yes No D-te of Survey: <br /> Proposed Se a ks: <br /> Front La e) : R ght Side: <br /> Rear ( tre= t) : eft Side: <br /> Adjac t St uc ures: - etland: <br /> Building H ight: D=f. Hgt. Peak Hgt. <br /> Avg. Setba k: Lot Coverage: <br /> 1lExisting P oposed <br /> Hardcover. 0-75' <br /> , 5-250 ' <br /> 2 0-500' 1 <br /> 50 -1000' ' <br /> Hardcover ariance Req 'ired Y -s No Date of Counci, Approval: <br /> Grading: S aff Approval Dat- : By: Council A. .roval Date: <br /> Septic: St ff Approval D- te: By: <br /> Zoning Fil :# • =solu io #: Resolutio Date: <br /> REMARKS (in house) : <br />