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r <br /> Shoreland District MCWD Permit Average Lakeshore Setback Bluff <br /> Met? <br /> � Yes 0 No Permit Number: 0 Yes � No � N/A � Ye No � , <br /> { <br /> ❑ N/A-see attached Setback: <br /> Stormwater Quality Existing Proposed ; <br /> Overlay District Tier Hardcover Hardcover Variance Required CUP Required ` <br /> circle one % and sf % and sf <br /> � Yes ❑ No 0 Yes ❑ No <br /> 1 2 3 4 5 Type(s): Type(s): <br /> Fees to be Char ed YES NO <br /> Permit <br /> Plan Review <br /> State Surcharge <br /> Investigation Fee <br /> SAC- Number of SAC Units <br /> Other(specify) <br /> Square Foota e $ per Square Foota e <br /> Basement X = $ <br /> 1 S� Floor X = $ <br /> 2nd Floor X = $ <br /> Garage X = $ <br /> Estimated Construction Value: $ <br /> Orono Inspections Required Work Requiring Separate Permits <br /> 0 Footing � Site � Plumbing 0 Grading/Filling <br /> � Poured Wall � Silt Fence/Erosion Control � Mechanical � Fire ; <br /> ❑ Foundation Survey ❑ Hardcover Removal � Septic � Water Connection <br /> � Foundation Waterproofing 0 Other(specify) ❑ Fireplace 0 Sewer Connection <br /> t � Framing 0 Masonry ❑ Lawn Irrigation <br /> � Insulation � Mfg. 0 Landscaping <br /> As-Built Survey � Other(specify) <br /> 0 Final <br /> � Lathe Required State Permits <br /> ❑ Other(specify) <br /> ❑ Well 0 Electrical <br /> REMARKS (in-house):�(�,V' V�J;���.� �-�'l,�- S�� � r�'C1�� r rl��U��I�r�.i:� i �� (`�y��ji�'YI l�'tQi <br /> I r 1 f�a i� r t�)��I���%E;���- <br /> OFFICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED: <br /> 0 See Builder Acknowledgement Form <br /> `�Prior to relea scrow mone`�j �a�-�as- uilt surve nd�ha�dcover calculations must be subrrritted and approved. <br /> ---_-- <br /> Updated: October 2015 <br /> �•\fnrmc\nlan ravia�ni rhar4lict 1(1_'J(1'I5(Inrv <br />