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ti; <br /> i{ Shoreland District MCWD Permit Average Lakeshore Setback gluff <br /> Met? <br /> Permit Number: , � Yes ❑ No N/A 0 Yes <br /> � Yes �No (p 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 sf % and s <br /> s � Yes No � Yes No <br /> 1 2 �� 4 5 � I � n r � <br /> 6 V (`� Type(s): Type(s): <br /> Fees to be Char ed YES NO <br /> Permit <br /> Plan Review � <br /> Stafie Surcharg� �,/ <br /> Investigation Fee � <br /> SAC—Number af SAC Units <br /> Other(specify) <br /> S uare Foota e $ er S uare Foota e <br /> �: Basement X = � <br /> 1S' Floor X = � <br /> 2nd FIOOf X = $ <br /> Garage X = � <br /> Estimated Construction Value: � ���D �_ <br /> � <br /> ` Orono Inspections Required Work Requiring Separate Permits <br /> � <br /> �3[' Footing 0 Site �Plumbing ❑ Grading/Filling <br /> � Poured Wall Silt Fence/Erosion Control �$'Mechanical ❑ Fire <br /> Foundation Survey � Hardcover Removal � Septic �(Water Connection <br /> ; � oundation Waterproofing � Other(specify) Fireplace �Sewer Connection <br /> � Framing ❑ Masonry � ;Lawn Irrigation <br /> � Insulation �Mfg. ` � Landscaping <br /> As-Built Survey ❑ Other(specify) <br /> � <br /> inal <br /> Lathe Required State Permits <br /> d Other(specify) <br /> ❑ Well �Electrical <br /> REMARKS (in-house): Wt�S S`�UN�� �C(i��/�j,�' �'�GQ..(�Q��j <br /> OFFICIAL REMA,RKS -TO BE NOTED ON PER(VftT At�D INITIALLED: <br /> See Builde Acknowledgement Form <br /> rior to crow mone a and hardcover calculations must be submitted and approved. <br /> �' <br /> Updated: October 2015 <br /> ` �•\fnrmc\nlan rAvia�u rhorklic4 1(1_�(115 rinrv <br />