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;�' <br /> - ' . � <br /> Average Lakeshore Setback <br /> Shoreland District MCWD Permit Met? Bluff <br /> � Yes ❑ No Permit Number. `� —��� Yes � No 0 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 % and sf % and s# <br /> �g-,q 9�� 0 Yes o � Yes �G'No <br /> �1 2 3 4 5 Type(s): Type(s): <br /> 53�L 5�.�' <br /> Fees to be Char ed YES NO <br /> �;� <br /> Permit � <br /> Plan Review U <br /> State Surcharge (/` <br /> Investigation Fee <br /> SAC–Number of SAC Units <br /> Other(specify) <br /> Square Foota e $ per Syuare Foota e <br /> Basement X = $ <br /> 15'Floor X = $ <br /> 2"� Floor X = $ <br /> Garage X = $ <br /> �7�– � <br /> Estimated Construction Vatue: $ � C�7 , � <br /> 4 <br /> t Orono Inspections Required Work Requiring Separate Permits <br /> Footing � Site Plumbing 0 Grading/Filling <br /> �Poured Wall Silt Fence/Erosion Control �5C Mechanical ❑ Fire <br /> Foundation Survey � Hardcover Removal 0 Septic � Water Connection <br /> Foundation Waterproofing 0 Other(specify) �Fireplace �Sewer Connection <br /> �Framing � Masonry � Lawn Irrigation ' <br /> Insulation �Mfg. 0 Landscaping <br /> �As-Built Survey Q Other(specify) <br /> Final <br /> Lathe Required State Permits <br /> � Other(specify) <br /> � Well Electrical �' <br /> REMARKS (in-house): 1pT ���Y�,,� �� I 1�( �Q KU � a��- l..l�Y ( ��91 <br /> �nc ,—�c.,h��d• <br /> ,' �� �EMARKS -TO BE NOTED ON PERMIT AND INITIALLED: <br /> �5ee o�„aer Acknowledgement Form <br /> i�Prior to releas .nf es row monev an as-built su�P"'�dcover calc.utat�r�i tt�}��ubmitted and approved. <br /> ��- —r':.----.o..�,_.�' -�' -`_"`^-,-�.,__�.�---•�—� <br /> , <br /> Updated: October 2015 <br /> �•\fnrmc\nlan roviaui nc�rlrlict 9(1_9(115 rinrv �� <br />