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RC. <br /> ��� <br /> Shoreland District t�fCIfVD Permit �,`;�� ���� �verage Lakeshore Setback B�u� <br /> Nlet? , <br /> � � Yes � No Permit Number. 0 Yes � No � N/A � Ye No � <br /> � N/A—see attached Setback: <br /> ' <br /> Stormwater Quality Existing Proposed <br /> � Overlay District Tier Flardcover Hardcover �ariance Required CUP Required <br /> circle one % and sf %and sf <br /> t 0 Yes � No � Yes Q No <br /> 1 2 3 4 5 Type(s): Type(s): <br /> ; � <br /> t <br /> ' Fees to be Char ec� YES PI� <br /> I; <br /> Permit � <br /> Plan Revievv �" <br /> State Surcharge ?�-- <br /> ` Investigation Fee <br /> SAC—Number of SAC Units �,�� <br /> � Other(specif�) <br /> S uare F"oota e $ er S uare Foota e <br /> t <br /> Basement X = $ <br /> � <br /> 1St Floor X = $ <br /> � 2nd Floo� X = $ - <br /> � Garage X = $ <br /> �� <br /> Estimafed Construction Value: $ ����� ���� � <br /> 3 <br /> Orono Inspections Ftequired Work Requiring Separate Permits <br /> 0 Footing ❑ Site 0 Plumbing � Grading/Filling <br /> s 0 Poured Wall 0 Silt Fence/Erosion Control 0 Mechanical � Fire <br /> ;:' � Foundation Survey ❑ Hardcover Removal ❑ Septic 0 Water Connection <br /> i ❑ Foundation Waterproofing ❑ Other(specify) CJ Fireplace � Sewer Connection <br /> � Framing � Masonry � Lawn Irrigation <br /> � lnsulation 0 Mfg. Q Landscaping <br /> ; 0 As-Built Survey � Other(specify) <br /> ' �d Final <br /> � ��.athe Required State Permits <br /> + � Other(specify) <br /> � Well � Electrical <br /> i <br /> , <br /> : <br /> � REMARKS (in-house): <br /> ; <br /> 6 <br /> � OFFIClaL 6�ENiaRKS -Ta BE hEQTED Qt� PERMIT a4ND INITIA�LED: <br /> � <br /> ��� � �ee BuilcEer Acknowledgement Form <br /> -' Q� Prior to release of escrow money an as-buift survey and hardcover calculations must be submitted and approved. <br /> r <br /> � � <br /> 3 �_� <br /> Updated: October 2015 <br /> �•\fnrmc\nlan ravic�u chceklict 9f1_9f115`inrtr <br />