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ENGIN7''R71'.^, UEPAf�TtdENT <br /> BUILDING PI3RMIT I*IFORI9AY'ION <br /> ADDRESS _ I I � �' - _ �'- :.L L-•.l. >{_ L;�' . TYPE :�,F',�' <br /> 1) BUILDING FERMIT FEE .-' S ��C� �' ' � ` $ /l�l. �'� <br /> (A) PLAN CfIECK F�E $ (�,Z, �^ n <br /> 2) WAiER SERVICE TO IIE PAID BEFORE BUILDING ' <br /> PERMIT IS ISSUED � �L�• `� <br /> (A) TO BE DETERFIINED BY PLBG. INSP. INCH G�y �/ ` ✓ <br /> M'Cu� (!o � ou <br /> (E) EXIST. WATER SERVICE, APPL. N0. � , <br /> . . (C) APPROX. LOCATION L �� G� .r Q l��'(«,y q r r ti( <br /> O� S L I tU l..f NE'' CHART ��L a� . <br /> 3) D�IVEIPAY PERMIT T BE� PAID HEFORE SUILDING �i� <br /> PER•1IT IS ISSU£D 2'S FT. ��5=1�/-� D/W (Tl'PE) $ �L' <br /> TOTAL* $ <br /> 4) S:nTUS� SEWER CHAR"'ES• <br /> . &O:r'D� DISTRIC'P Z� FOOTAGE <br /> N, S, E, W. <br /> NOTES • SEWER CONNECTION CHARGES: <br /> YEAR � TRUNK $ I `�� �Od <br /> _ -x -7cJ — � U � , `�U <br /> y. ,l,� J J TOTXL CONNE�YIOId�CFfARGE $ 2 CTI� '�U <br /> SEWER PERMIT FEE g '�� C U <br /> � CATCH rASIN PERMIT FEE S <br /> TOTAL SEWER PERI�IIT FEES S �..�J �'� <br /> 5) ::J::;iiLY SEIv'ER CHARGES: <br /> SEWER CONSTRUCTION: <br /> . TRUNK S ( •I �� <br /> LATERAL $ 'l ��c:� <br /> SEWER SERVICE: S �'��� ' <br /> APPRJ\. LOCATION OF SIDE SEWER OR TEE IN THE MAIN: f�('/��'Cx � i- <br /> _ � �� � F�r F%l�-I :� /�/'��/'� � [�� � :- i_ -�t � � is r 1�1�0i-' G� <br /> CHART �',�. '1- 7 ;- .. <br /> INFO :.J?:PILED SY: DATE <br /> REVIEt�: DATE <br /> PROJECTS DIVISION <br /> APPROI'AL: DATE <br /> ENGINEGI2ING DI:1'ARTMENT <br />