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i <br /> ADDFtESS � �/ D `-' /-;.J % % DATE /;_` <br /> TYPE OF BUILDING L� - /-'l�- � <br /> {1) BUILDING PERMIT FEE $ � � �, (- ('� <br /> (A) PLAN CHECK FEE $ .,-,� � % '. <br /> (2) �1'ATER SERVICE TO BE PAID BEFORE BUILDI�IG <br /> „ , i� � � <br /> PcRMIT IS ISSUED $�),�', <br /> !A) TO BE DETERMINET_J BY PLBG. INSP. I INCH <br /> (B) EXISTING �Z / INCH NATER SERVICE <br /> APPLICATION NO. ,S 2. l r_ <br /> !3) DRIVEVlAY PERMIT TO E3E PAID BEFORE BliILDIATG <br /> PERMIT IS ISSUED — FT. — D/W (TYPE) $ '—' <br /> L��LL ���Tf2 ��FF �� CC�>5° • <br /> TOTA.L ;= <br /> . � <br /> (4) STATUS OF SE�VER CHARGES: ��C�� ? . r _ <br /> LIOND -- DISTRICT — rOOTAGE <br /> N, S, E, �1' <br /> S��VLR COi�i�T�CTION CHARGE�: <br /> TRUNK $ ` <br /> LATERAL $ — <br /> TOTAL CONNEC'I'ION CHAP.GE $ � <br /> SF:�YER PERMIT FEE $ �C��r U O <br /> CATCH BASIN PERbIIT FEE $ , � L �� <br /> TOTAL SEtiVER PER\-fIT FLES $� �Z/in(J <br /> (5) ivtONTHLl' Sr�'�'=FC CiitlRGrS: <br /> Sl�ti:i'R CO:`�STRliCTION: <br /> TRUNK � ' _ i <br /> _ I <br /> LATE RA L $ � <br /> s,�.wLit ����vic� g i-;'- i;-/-%.;� � <br /> '.COTAL $ /Vi P%�,l�.C� � <br /> LOGATION OF SII?� S �1'ER OR TEE Ii1 THE MAIN: <br /> `�:z�e�e C�P�-�L� ,�+�a/���� c��� �z � C BF C'�,�� 5 � Sa, nF ��l'D� <br /> � �D� �-S��U�IL�/t" I/IL�FfC�( ��C�' J�./SIE C�T.S r� �I� / 'Y. �� 1 <br /> � Y� �F �' �'r�l✓Noc f' � , � r�'' '�' <br /> /'-` G.z f'SE'Q �J lL',.I�FO ('yOMPILED BY �._,_ <•,; � � �..{.'.. <br /> `This total must be paid before ��- /%/i,F' <br /> building ncrmit is issucd DATE � ' <br /> I <br />