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Shoreland District MCWD Permit Average Lakeshore Setback Bluff <br /> Met? • <br /> Permit Number: � Yes 0 No 0 N/A � Yes O <br /> 0 Yes � No No <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 /> 0 Yes 0 No 0 Yes 0 No <br /> 1 2 3 4 5 Type(s): Type(s): <br /> Fees to be Char ed YES NO <br /> Perm it <br /> Plan Review �/' <br /> State Surcharge (/� <br /> Investigation Fee � <br /> SAC— Number of SAC Units <br /> Other(specify� <br /> Square Footage $ per Square Foota e <br /> Basement X = $ <br /> 1 S� Floor X = $ <br /> 2nd FI00� X = $ <br /> Garage X = $ <br /> Estimated Construction Value: $ <br /> Orono Inspections Required Work Requiring Separate Permits <br /> � Footing 0 Site Plumbing � Grading/Filling <br /> � Poured Wall � Silt Fence/Erosion Control Mechanical � Fire <br /> 0 Foundation Survey � Hardcover Removal � Septic � Water Connection <br /> 0 Foundation Waterproofing � Other(specify) � Fireplace � Sewer Connection <br /> Framing 0 Masonry � Lawn Irrigation <br /> �Insulation � Mfg. 0 Landscaping <br /> � As-Built Survey � Other(specify) <br /> Final <br /> � Lathe Required State Permits <br /> � Other(specify) <br /> 0 Well Electrical <br /> REMARKS (in-house): <br /> OFFICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED: <br /> � See Builder Acknowledgement Form <br /> ❑ Prior to release of escrow money an as-built survey and hardcover calculations must be submitted and approved. <br /> Updated: October 2015 <br /> �•\fnrme\nlan ravic�ni rhorklict 1!1_7(11F rinrv <br />