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� <br /> � Average Lakeshare Setback <br /> Shoreland District f�iCl�l� Perm6t tMet? �'.�" <br /> � Yes No Permit Number. �� -( �� Q Yes a No �N/A � Ye�o <br /> � � <br /> � N/A-see attached Setback: <br /> Storrrnvcra�er Qual6ty Ex�stie�g Fropose8 <br /> �verlay Qistrict Tier FQ�rdca�er !#�.rdc��er 9�ariae�ce 8�eq�irec� CUF� I�equirec€ <br /> circle one % and sf °/o and s <br /> �I Yes No � Yes No <br /> ` - _- - ___-=- ----=� <br /> 1 2 3 4 5 -_� ___-- -- - Type�s�. Type�s�: <br /> Fees to be Char eci YES NO <br /> Permi� ✓'' <br /> F�Qan Revie�nr „�" <br /> St�te Surcharg� Z-�-. <br /> ie��e��i��tior� �ee � <br /> ��C-�&umber o#�AG l�r�its � <br /> O�her(s�eci�r) � <br /> �quar� Foota e � �r S uare Foota e <br /> - Basement ( C ��=;� X G'C%' � - $ l���0� �" (�` <br /> 1 st Floor ��"'�� X ��i�. �(�� _ $ r Jr�' '(�)��� <br /> - 2"d FIOOf �� ''` Y �'���; . � _ $ �� ��,�' G- � � <br /> � �. � <br /> Garage ��-,��;t��: (`,��l�- X �/ _ $ .� ,� �`J <br /> 4�� + ..�, �' <br /> Estimat�d C�nstruc4ior� Vai�ae: $ �� � �; �fi :� <br /> �rc��r� fnspecti�ns Rec�uired !"�ork�equBrin� Separate Permits <br /> ��- Footing � Site `�Plumbing Q Grading/Filfing <br /> �Poured Wall �ilt Fence/Erosion Control �.Mechanical � Fire <br /> � 4,6� Fo�ndation Survey C'� Hardcov�r Removal Septic � Water Connection <br /> � Foundation Waterproofing C1 Other(specify) �Fireplace � Sewer Connection <br /> ,�Framing Cf Masonry � Lawn Irrigation <br /> �Insulation �Mfg. ❑ Landscaping <br /> As-Built Surwey E3 Other(specify) <br /> �Final <br /> � Lathe Rec�uired Stafi� Ferrnit� <br /> � Other(specify) <br /> � . �• <br /> 1/Vell Electrical <br /> f� <br /> REit�e�R6C3 (in-house): ' <br /> �FFICIi4L REfi��RK� -T� BE Rl�TED O�' �EI?F�ff@T A,N� I[�ITl�@,LLE�: <br /> e� Builc�e Ackno�led�e�er�� �orrn <br /> � <br /> � r tQ-� escr9. as-b " ur.�e�+ _ . <br /> --___�_,�.- <br /> �' <br /> Updated: October 2015 <br /> �•\fnrmc\nlan rcview rhorkliet 1(1_9f11 F rinrY <br />