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� :��, � Average Lakeshore Setback 8��� <br /> Shoreland District hRClNE3 �ermit ^,,,�; �,�_ �e�� <br /> Yes Cl No Permit Number: ��; � <br /> , � C7 Yes Q! No �N/A i3 Ys No <br /> � Q N/A—see attached Setback: <br /> Stormwater Quality Existing ProPosed <br /> Overtay District'Cier Harc�cod�r t�ardcover Variance Required CUP Reguired <br /> circle one %and sf %and sf <br /> ��.�pa� ����q Q� Yes -� No � Yes No <br /> 1 2 �'3',� 4 5 _ . , _ (s : � TYPe�S)� <br /> `.�� ��� � _!� . _-b� f-NI� <br /> ��i�9�1�- ��� b�- 1_�°C� <br /> Fees to be Char ed YES h0 <br /> Permit` <br /> Plan Revisw <br /> State Surcharge <br /> Inves#igation Fee <br /> S�:C-�umber of�AC Units , <br /> Other(specify) <br /> S uare Foota � $ er S uare Foota e <br /> Basement <br /> x .7 = $ 3 _7 <br /> 1St Floor 'Zo X ��� � _ $ z, dI�-�.Q <br /> 2^� F�oor (�J x �O . � _ $ � 1 7 � � l�— <br /> Garage (� �}"O X ��. � _ $ � �P � �t • �� <br /> Estimated Construction Value: Z � �� � <br /> Orono Inspections Required Work Requiring Separate Permets <br /> Footing � Site � Plumbing � Grading/Filling <br /> Poured Wal1 ilt Fence/Erosion Controt � Mechanical D Fire <br /> F o u o d a t i on Surve y � Hardcover Removal CI Septic �Water Connection <br /> Foundation Waterproofing 0 Other(specify) �fireplace �Sewer Cannec tion <br /> F r a m i n g O Masonry � Lawn Irrigation <br /> Insulation �Mfg. 0 Landscaping <br /> /�s-Built Survey Q Other(specify) <br /> Final <br /> Lathe Required State Permits <br /> Q Other(specify) <br /> � Weli Electrical <br /> REh7ARKS (in-house): <br /> QFFICEAL RE�fff�RKS-TO BE hEQTEa Oht FERtc�iT�#,E�Cf EFEITtALLED: <br /> �See B�ilder 1i,cknowtedgement Form <br /> rio�to re e of e v cal must be submitted and approved. <br /> ��..,lero.l• llrtnhar 9(11.ri <br />