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ADDRESS � �� % <br />TYPE OF BUILDING <br />BUILDING PERrifIT INFORP�fATION <br />LF�/�1.9�� �c' <br />S � <br />1) E�UILDIITG PERMIT FFE <br />(�1) PLAN CHECK FEE <br />Z) �VATER SERVICE TO BE PAID BEFORE BUIL,DING <br />PERMIT IS ISSUED <br />(A) TO BE DETERMINED BY PLBG. INSP. INGH <br />3 �� n <br />(B) EXIST.��_ WA1'Ei2 SERVICE, APPL, N0.1a IC�� <br />(C) LOCATION %b SO P�L <br />CHART /V- 99 <br />3) DRIVESVAY PERMIT TO BE PAID BEFORE BUILDiNG <br />PERIviIT IS ISS:7ED FT. D/�V (TYPE) <br />TOTAL>�� <br />4) STATUS OF SEtiVER CI-LARGES: /t�OQ� E/V�J <br />BOND DISTRICT FOOTAGE <br />N, S, E, tiv. <br />SE11rER CONNECTION CHARGES: <br />TRUNK <br />LATERAL <br />TCTAL CONNECT;ON CHARGE <br />iEWER PERMIT FEE <br />�ATCH BASIN PERiviIT FEE <br />TOTAL SEWER PERMIT FEES <br />5) I�10N'I'iiLY SE\t'ER CHARGES: <br />SE�VER rpNS'fRUC'I'ION: <br />SEWER SERVICE: <br />;.00ATIOr? OF SIDE <br />C�}F'�iZO n,v � <br />�D ` 6c+, n F Nd, <br />iNFO COMPILED BY <br />.� <br />REVIEW: � <br />1�J�v ��i,.� �15p _ � <br />APPROV,4/i. ��ll. <br />TRUNK <br />I,ATERAL <br />OR TEE LN THE MAIN: CHART <br />�/ AF'✓%c"J,K' /�f G L�F �r;� <br />� <br />a ' F� <br />°?This total must be paid before building permit is issued. <br />/�'�9a � <br />���/�- <br />DE�TE �'aU-TJ- <br />$ % �f ; L� c'i <br />� � � <br />s ^ � c , rl <br />$ S/C^�i TUr✓ -ON" <br />�� �. <br />� O �t� <br />� 11 �/. ��� �, <br />$ <br />$ <br />$ ='� ' J C� <br />,� D ���i -S <br />G /JirtF� i9�Y�t�rk- <br />DATE � -��/•7f <br />DATE �i/�'/�7 S` <br />DATE <br />