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1 <br /> Shoreland District MCWD Permit Average Lakeshore Setback Bluff <br /> Met? <br /> ❑ Yes � No Permit Number: � Yes � No 0 N/A � Ye Na � <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 sf <br /> � Yes 0 No � Yes 0 No <br /> 1 2 3 4 5 Type(s): Type(s): <br /> Fees to be Char ed YES NO <br /> Permit <br /> Plan Review '� <br /> State Surcharge <br /> Investigation Fee <br /> SAC— Number of SAC Units <br /> Other(specify) <br /> Square Foota e $ per Square Footage <br /> Basement X = $ <br /> 1 St Floor X = $ <br /> 2nd FIOOr X = $ <br /> Garage X = $ <br /> �q ✓ <br /> Estimated Construction Value: $ `'I'��i z�j�" <br /> Orono Inspections Required Work Requiring Separate Permits <br /> 0 Footing 0 Site Plumbing ❑ Grading/Filling <br /> 0 Poured Wall 0 Silt Fence/Erosion Control � Mechanical 0 Fire <br /> 0 Foundation Survey 0 Hardcover Removal 0 Septic � Water Connection <br /> 0 Foundation Waterproofing 0 Other(specify) � Fireplace ❑ Sewer Connection <br /> raming 0 Masonry ❑ Lawn Irrigation <br /> Insulation ❑ Mfg. 0 Landscaping <br /> � As-Built Survey 0 Other(specify) <br /> Final <br /> � Lathe Required State Permits <br /> 0 Other(specify) <br /> � Well Electrical <br /> REMARKS (in-house): <br /> OFFICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED: <br /> � See Builder Acknowledgement Form <br /> 0 Prior to release of escrow money an as-built survey and hardcover calculations must be submitted and approved. <br /> Updated: October 2015 <br /> ��\fnrmc\nlan ravia�u rharklict 1(1_9(11�i rinrv <br />