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_ <br /> Shoreland District MCWD Permit Average Lakeshore Setback g�uff <br /> Met? <br /> �� Yes � No Permit Number: 0 Yes � No N/A � Ye No <br /> N/A–see attached Setback: <br /> Stormwater Quality Existing Proposed <br /> Overlay District Tier Hardcover Hardcover Variance Required CUP Required <br /> circle one °/o and sf °/o and s <br /> � Yes No � Yes No <br /> � 2 3 4 5 � ( ^� � Type(s): Type(s): <br /> l./ �l� ( �� <br /> Fees to be Char ed YES MO <br /> Permit <br /> Plan Review (/' <br /> State Surcharge j/` <br /> Investigation Fee <br /> SAC–Number oi�SAC Uni#s <br /> Other(specifyj <br /> S uare Footage $ er Square Foota e <br /> Basement X = $ <br /> 1 St Floor X = $ <br /> 2nd Floo(' X = $ <br /> Garage X = $ <br /> Estimated Construction Value: ('�"''V <br /> ` �'— <br /> Orono Inspections Required Work Requiring Separate Permits <br /> _ � Footing � Site Plumbing 0 Grading/Filling <br /> 0 Poured Wall �Silt Fence/Erosion Control echanical 0 Fire <br /> �oundation Survey 0 Hardcover Removal 0 �eptic � Water Connection <br /> 0 Foundation Waterproofi � Other(specify) ireplace C7 Sewer Connection <br /> raming ❑ Masonry 0 Lawn Irrigation <br /> -Insulation �Mfg. 0 Landscaping <br /> As-Built Survey � Other(specify) <br /> inal <br /> � Lathe Required State Permits <br /> 0 Other(specify) <br /> �� � Well � Electrical <br /> REMARKS (in-house): %tm�(�C1YL-P�f'l�J �tiZ�' �l � � Yi���--- <br /> � Y�— � r61'`ed �a✓- /k,�2 - . � �al-� . <br /> OFFICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED: <br /> �See Builde Acknow{edgement Form <br /> � Prior to releas of escrow money an as-built survey and hardcover calculations must be submitted and approved. <br /> Updated: October 2015 <br /> ��1f�rmc\nlan rovio�u rharklic4 1(1_9(115 rinrr <br />