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�-���� -�...f-�.ve<���:��-�a,�� -- - - - <br /> �,. �� � , ��� :. _.�_�� _. ��,- <br /> �d.,-v. r_.,aaw�e F• ..�r�.z <br /> c.��� �.. .. ,. . ... . ... ._ ., �a .. . . . <br /> Average Lakeshore Setback g�uff <br /> Shoreland District MCWD Permit Met? <br /> � �� `��� � Yes <br /> �Yes ❑ No Permit Number: � Yes 0 Na �A No <br /> 0 N/A-see attached Setback: <br /> Stormwater Quality Existing Proposed <br /> Overlay District Tier Hardcover Hardcover Variance Required C�JP Required <br /> a circle one % and sf % and sf <br /> ��'"j� � Yes No O Yes o <br /> 1 2 3 4 5 �n ��� Type(s): Type(s): <br /> �� <br /> `� Fees to be Char ed YES NO <br /> Perim It � <br /> Plan Review <br /> State Se�rcharge �" <br /> Investigation Fee <br /> ; _ <br /> SAC-Number of SAC Units �� _°r�,ap��r , f,�, 3' ` %,r -'� � ; �' <br /> Other(specify) <br /> Square Footage $ per Square Foota e <br /> Basement X - $ <br /> 1 St Floor X = $ <br /> 2nd Floor X - $ <br /> Garage X - $ <br /> Estimatec! Constructian Vaiue: $ � `f i ��� <br /> Oror�o Inspections Required Work Requiring Separate Permits <br /> Footing � Site Plumbing ❑ Grading/Filling <br /> 'Poured Wall �Silt Fence/Erosion Control �Mechanical 0 Fire <br /> oundation Survey O Hardcover Removal 0 Septic Water Connection <br /> " Foundation Waterproofing � Other(specify) � Fireplace Sewer Connection <br /> Framing ❑ Masonry ❑ Lawn Irrigation <br /> � Insulation ❑ Mfg. � Landscaping <br /> As-Built Survey 0 Other(specify) <br /> Fina► <br /> ❑ Lathe Required State Permits <br /> � Other(specify) <br /> 0 Well 0 Electricaf <br /> ;': <br /> REMA.RKS (in-house): <br /> ,: OF�fClAL REMARK� -TO BE �lOTED ON PERMIT AND INITIALLED: <br /> See Builder Acknowledgement Form <br /> � rior t�1 "�of escrow,mone.y�as-��`?c�,.�nd�_hardcover calculations m �tted and approved. <br /> 5. � �� _m�" _ <br /> } <br /> Updated: October 2015 <br /> ��\fnrmc\nlan rovia�u rharklic4 1fl_9f11F`inev <br />