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�� <br />I,��,� �.,��..� Uf�f; 0:�lf,Y <br />LNG.CiJcF;RI[JG e1h1U CO;;f�1Ut77'PY SFRVICi:S <br />IIUILDING PP•.R;tIT INPORh1i�T2UN <br />AGllitGSS <br />1) IIUILDING PEIL'1IT T'�E <br />, (A) PLI�t7 ��fI�CK FEE <br />2 ) PLUMI3ING � <br />TYPE <br />3 ) MECHl1NICAL � <br />4) [�ATER SE?2VIG� TO BE PAID B�PORE BUI7•DING <br />Plifdti•1' 1S ISSJF.D ' <br />(A) TO BE DETERMIyED 9Y PLBG. ZNSP. INCH <br />(�) PXIST. _ idATER SBRVICE, APPL. N0. <br />{C) APPi20X. LOCATIOid <br />$ <br />CHART <br />5) DBIVET9AY PER;tIT TO B� P11ID Bi:FOBE IIUIi,DING � <br />P�IZ�SIT IS ISSUED FT. D/P1 (TYP�) S <br />6) STA:US OF S�?�ER CHARGES: TOTAL $ <br />BO*ID DISTRICT PGOTAGE <br />N, S, E, VT. <br />7) .`;OD1TEiLY SI;�•.rR CEIARG�S: <br />Sli?�IER COtdS`L'RUC'SION: <br />SEIVER CON.y�CTION CII71RGE5 <br />YrAR �RUVK $ <br />LATERAL $ <br />TOTAL CONAIECTION CFIARGE$ <br />F- O G� <br />SB'';ER PER�tIT PEE S U� �� <br />CATCH �iASIN PEI2�`IIT iEE $ �Z U <br />'POTAL SP:t•?�R PERi4IT I'EES$ '-`� d '•�•�� <br />TRUNK <br />LnTEIL1L <br />SPC4I;R SL•'I2VICE <br />P�PPI:O`{. LOCel'f.COiQ O1:' STUI; SP•.'9E3 012 'PP;I: ICl T(lI: i.i[IIN: <br />T�dPO CO?dP.iLED 13Y: <br />�APi'ROV�AT,: <br />CIfART <br />DA'i'E <br />D:�'CI; <br />$ <br />$ <br />S <br />