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s • <br /> FOR OFFICE USE ONLY <br /> ADDRESS___ <br /> (1) BUILDING PEFAI:T FEE $ <br /> (A) FLAN Cf:� . � � - -- <br /> (2) PLUMBIf:3 — — <br /> (3) MECHANICAL <br /> (4) STATE SURCHAHGES <br /> (A)BUILDING CODE <br /> (B) ENERGY GOPE - -- <br /> (5) DRIVEWAY PERMIT <br /> $ <br /> (G) WATER SERVICE TO BE PAID PRIOF TO BUILDING PERMIT ISSUANCE 5 S O �J 7 R 9 <br /> 0 <br /> (A) TO BE DETERMINED BY BLDG.INSPECTOR._��NCH 7/�/�/d <br /> (B) EXIST. WATER SERVICE.APPLICATION NO. <br /> (7) STATUS OF SEWER CHAFGES: <br /> BOND DISTRICT _FOOTAGE <br /> N. 5, E. rV <br /> SYSTEMS DEVELOPMENT � � / <br /> WaTER ��� <br /> SEWER — <br /> TOTAL ORD.FEE <br /> SEWER CONNECTION CHARGCS <br /> YEAR TRUNK $ <br /> LATERAL <br /> TOTAL CONNECTION CHARGES $ <br /> �� /J <br /> SEWERPEFMITFEE � 3�bU' $ �b V,.'1/� <br /> i= <br />