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� � <br /> FOR OFFICE USE ONLY <br /> ADDRESS._ <br /> (1) BUILDR.(i�ERMITFEE S <br /> (A) PLAN CHECK FEE <br /> 12) PLUMBWG <br /> l3� MECHANICAL <br /> �4) STATE SURCHARGES <br /> �A�6UILDING CODE <br /> (�) ENEfiGV CODE <br /> IS) DRIV[WAY PERh11T <br /> 5 � <br /> (fi) VJATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT ISSUANCE $ _ / - /�� (�lyy� <br /> (A) TO BE DETERMMED BY BLDG.INSPECTOR INCH � _ a/.�� ���h <br /> (B) EXISL _WATER SERVICE.APPUCATION N0. l �y <br /> (7) STATUS OF SEWER CHARGES: / � �'Y'e <br /> OOND DISTRICT _FOOTAGE <br /> N, S. E. 1Y <br /> SYST�EMS DE\'ELOPMENT <br /> ;,-� iir,� Ci(i� :i..�!� � I,O�I = WATER <br /> j]��- C SEWER <br /> TOTALORD.FEE -�fQz7 — �� <br /> �' r, ,i[l� �,�� �.i1= 25�JZ - <br /> f2Z/ ' SEWCRCONNECTIONCHARGES <br /> YEFR TRUNK S __ <br /> �� <br /> �r.t l�G2 - LATERAL <br /> jfj' �-<�✓ /f�j7 TOTALCONNECTIONCHARGES S <br /> SEWER PERIJIIT F[E 5 ___�, � <br /> �L <br />