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,�.� t,�� <br /> Average Lakeshore Setback <br /> Shoreland District MCWD Permit - `y� Met? Bluff <br /> �Yes � No Permit Number: (5— ��? 0 Yes 0 No �I/A � Ye No <br /> 0 N/A–see attached Setback: <br /> Stormwater Quality Existing Proposed <br /> Overlay District Tier Hardcover Hardcover Variance Required CUP Required <br /> circle one % and s %and sf <br /> a•L7�70 � Yes No 0 Yes No <br /> 1 2 � 4 5 �� Type(s): Type(s): <br /> g(ot3SF <br /> Fees to be Char ed YES NO <br /> Permit 1/r <br /> Plan Review <br /> State Surcharge � <br /> Investigation Fee <br /> SAC–Number of SAC Units <br /> Other(specify) <br /> S uare Foota e $ per Square Foota e <br /> Basement X = $ <br /> 1�Floor X = $ <br /> 2nd Floo� X = $ <br /> Garage X = $ <br /> Estimated Construction Value: $ ��1 �� <br /> Orono Inspections Required Work Requiring Separate Permits <br /> Footing 0 Site lumbing 0 Grading/Filling <br /> Poured Wall Silt Fence/Erosion Control Mechanical � Fire <br /> oundation Survey 0 Hardcover Removal Septic 0 Water Connection <br /> Foundation Waterproofing � Other(specify) ireplace 0 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 /> Well Electrical <br /> REMARKS (in-house): <br /> OFFICIAL REMARKS-TO BE NOTED ON PERMIT AND INITIALLED: <br /> �See Builder Acknowledgement Form <br /> o re ow mon s-built an ' ed and approved. <br /> Updated: October 2015 <br /> �•\fnrmc\nlan rovio�u nhAnklict 1 fl_9(11 R r�nnv <br />