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r � <br />FOR OFFICE USE ONLY <br />ADCRESS <br />(1) BUILDING PEfiMIT FEE <br />fA! PLAN CHECK FEE <br />(2) PLUMBING <br />(3) MECHANICAL <br />(A) STAfE SURCHARGES <br />(A) fUIIDING CODE <br />([3) ENERGY CODE <br />(5) DRIVEWAYPERMIT <br />(6) WATER SERVICE TO BE PAID PRIOR TO EUILDING PEflMiT ISSUANCC <br />(A) TO BE DETERMINED BY BLDG. INSPECTOFl �+ INCH <br />(0) EXIST. Wl,TER SERVICE. APPLICATION N0. ___ <br />(7) STATUS OF SEWErI CHARGES: <br />BGND DISTRICT _FOOTAGE_ <br />N, S, E, W <br />SYSTEMS �EVELOPIAENT <br />WATER <br />SEWER <br />TOTAL ORD. FEE <br />'iEWER CONNECTIGN CHARGES <br />'fE,1R _TRUNK <br />LATERAL <br />TOTAL CONNECTION CHARGES <br />SFWER FERMIT FEE <br />a <br />$ <br />�J f` j-'�:�., <br />- �7a� � �_�.i��� <br />% <br />�7/l / <br />/ �' — <br />. <br />i�� <br />S <br />� <br />E � <br />a 7n <br />