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� CHECK OFF LIST FOR ISSUANCE OF PERI�IITS <br /> FOR OFFICE USE ONLY • . <br /> ADDRESS OR LEGAL: �i 4 � o x�02�,0 ��� <br /> PID: <br /> DESCRIPTION OF WORK: (Z;c—w�c,o�� <br /> ZO��G REY�tiv BY: DATE APPROVED: N��� <br /> �. BLZLDl�iG REVIE�V BY: � DATE APPROYED; 2-�.3-oti <br /> FEES TO BE CHARGED: Misc. Fees Calculated By: <br /> PERMIT Yes �/' No <br /> pI,AN REV�W Yes ,/ No SERTF..R COY�TFCIZON <br /> STATE SURCHARGE Yes_� No tiVATERCONNECTTON <br /> INVESTIGATION FEE Yes No p��E <br /> SAC Yes No SIT��i tSPEG"TION <br /> Number of SAC•Units OTHER(specify) <br /> _ _ -------- <br /> ZO�Zti'G CH�CS LIST Zoning District: No cil��4=�� <br /> Fire Department: Post Office: School Dstrict: • � <br /> Lot Area: Sq.fr. Acres ' idth Depth <br /> Survey Submitted: Yes No Date of Survey: <br /> Proposed Setbacks: <br /> Front(Lake): Right Side: � - � . <br /> Reaz(Street): Left Side: <br /> Adjacent Suuctures: Wetl . <br /> Building Height: Def. Hgt. Peal: gt. <br /> Lot Covera�e: ' <br /> Gradin;: Staff Approval Date: By Council Appro��1 Date: <br /> Septic: Staff Agproval Date: By: <br /> Zonin�File: # Resolution: # Resoludon Date: <br /> Shoreland District: <br /> Av�. Setback: Bluff Setback: Lot Co��ra�e: <br /> � Existmg Progosed <br /> Hazdcover: 0-?5' . <br /> . 75-250' -- <br /> 250-500' <br /> 500-1000' <br /> Hazdcover Variance Required: Yes No Date of CouncL Approval: _ <br /> REVLA.RKS('in house): � <br /> 7 <br />