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FOR OF�ICE USE �DNLY <br /> ADDRESS <br /> (1) BUILDING PERMIT FEE $ <br /> (A) PLAN CHECK FEE � <br /> (2) PLUMBIIVG <br /> (3) MECHANICAL <br /> (4) STATE SURCHARGES <br /> (A) P.�JILDING CODE _ <br /> (B) ENERGY CODE <br /> (5) DRIVEWAY PERMIT <br /> $ <br /> (6) WATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT IS:�UANCE $ �LV <br /> (A) TO BE DETERMINED BY BLDG. INSPECTOR INCFi <br /> (B) EXIST. WATER SERVICE.APPLICATION NO. _ <br /> (7) STATUS OF SEWER CHARGES: <br /> BOND_ DISTRICT __FOOTAGE <br /> N, S. E, �V <br /> SYSTEMS DEVELOPMEfJT <br /> WATER ��, <br /> SEWER �� <br /> TOTAL ORD. FEE ,����% <br /> SEWER CONNECTION CHARGES <br /> YEAR TRUNK $ <br /> LATERAL <br /> TOTAL CONNECTION CHARGES S � <br /> SEW[R PERMIT FEE $ �G� <br /> 11��� @ 5�7� �0 ���5-- <br /> ' • //9l @ �7 3 20 /�� <br /> ' � iG//�� <br />