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� � <br /> FOR OFFICE USE ONLY <br /> ADDRESS_ <br /> (1) BUILDING PERMIT FEE $ <br /> (A) PLAN CHECK FEE <br /> (2) PLUMBING <br /> (3) MECHANICAL _ <br /> (4) STATE SURC�iARGES <br /> (A) BUILDIN�, CODE <br /> (B) ENERGY CODE <br /> (5) DRIVEWAY PERMIT <br /> $ //2.�� <br /> (6) WATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT ISSUANCE $ _�(Af�Y.� _ <br /> (A) TO BE DETERMINED BY BLDG. INSPECTOR INCH T �-/-9d S,O• �SD <br /> (B) EXIST. WATER SERVICC.APPLICATION NO._ <br /> (7) STATUS OF SEWER CHARGES: <br /> BOND DISTRICT FOOTAGE <br /> N, S, E, W <br /> SYSTEMS DEVELOPMENT <br /> WATER - �/�4 2- <br /> SEWER !O IO <br /> TOTALORD. FEE 7 72 <br /> SEWER CONNECTION CHARGES <br /> YEAR TRUNK $ <br /> LATERAL <br /> TOTAL CONNI_CTION CHARGES $ <br /> SEWER PERM!T FEE $ —�Q <br /> ,�'3� � ��7� U2 2�.5' <br /> .S�SC (� /C�,7 ��8� j(���SG� <br /> � �� <br /> �3a @ i� 3 �/1��9 <br /> �6 � i3.s /Cfb <br /> �b� <br />