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I3UILDING PERVIIT INI� OR\tATION <br />AGDRESS �_�� � � � (�C�� �� <br />TYPE CF BUILDING �S^, v`= `� <br />l) IIUILDI.�IG PERh1IT FEE GOT <br />(A) PLAN CHECK FEE � <br />z' PEREIT SI SUED O BE PAID BEFORE IIUILD� GU��uJ <br />-�i <br />(A) TO BE DETER,� INED BY PLBG, INSP, �S//� INCH <br />(B) EXIST. �VATER SERVICE, APpL NO. <br />(C) LOCATION �N r� 1� �� �����2,�Ty ('n,(�jyP,,� <br />' CHART �j - a� 1 <br />3) DRI�'E�VAy PER\fIT TO IIE PAID IIEFOR� EiUII DING <br />PER\iIT IS I55:7ED `;a,.j FT. 1,- ,�,� Q,1T� D/1V �TYPE) <br />5 ( o�� 5 U � <br />TOTAL ` $ Z!�%.� �t� <br />4) ST.4TUS OF SEIVER C'-IARGF.S: <br />BOtiD_ yL DISTRIUT ,J'O FOOTAGE <br />N, S� �, �V. -- <br />L�NDSCAPE NOTES SE�VER CONNECTION CI-IARGES: ,. <br />TRUNK � $ ��D r) v `� <br />LATERAL I� � '�'��'� r"�-' <br />TOTAL CONNECTION CHARGE $ j�G v� <br />SE�VER PERIvi1T FEE $ �Q, U ('� <br />CATCH BASIN PERMIT FEE <br />TOTAL SE�VER PERMIT FEES <br />5) MONTFiLY SE�VER CHARGES: <br />SE�VER CONSTRUCTION: <br />TRUNK <br />LATERP.L <br />� <br />$ .'. /S <br />$ -- — <br />SEWER SERVICE: � ,:1, �,, Q <br />LOCATION OF SIDE SEWER OR TEE IN THE MAIN: CHART -� - d'" -�� - J <br />sruB�'�� To A L �' F�'c�M �V,�, P,('aP�,r�rr c���v,2,� �P�,���Y <br />�-��_� <br />INFO CO�iPILED BY: ` <br />REVIEW; i <br />APPROVAI <br />This total muat be paid before building permit is iesued. <br />DATE 5�'- <br />DATE 9 z. 7 <br />DATE � � �,J� <br />