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<br /> �` ADORESS ' `3 7/5 /)n/--^� /�✓2 —TYPE C�4/ �'`' �.:�, .
<br /> (1) BUILDING PERMIT FEE
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<br /> ' (A) PLAN CHECK FEE p� °G
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<br /> � (2) PLUMBING , r./� "o
<br /> `� (3) MECHANICAL � ��-p o�
<br /> (•1) WATER SERVICE TO BE PAID PRIOR TO BUILDING PER�IT ISSUANCE —�2—
<br /> � INCH
<br /> (A) TO BE DETERMINED 8Y BLCC INSPECTOR �
<br /> � (B) EXIST. WATER SERVICE, APPLICATION NO.
<br /> '� (C) APPROX. LOCATION
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<br /> • CHART
<br /> ' ' �(5) DRIVEWAY PERMIT TO BE PAID PRIOR TO BUILDING PERMIT IS- � �
<br /> •`i' " ' PEET DRIVEWAY(TYPE) f
<br /> I� ' :'•�r:•. SUANCE _---- s
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<br /> � ��; (7) STATUS OF SEWER CHARGES: FOOTACE _ .
<br /> e DOND �—DISTRICT � <,
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<br /> ; __._ . NOTES '
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<br /> ,+.�n;�� SEWER CONNECTION CHARGES �70� '
<br /> ~'`������• TRUNK S
<br /> ,,�,�., r, .' ,: �. YEAR Si��-D,Q-o. • :
<br /> '-4` '` LATERAL -
<br /> ,,:. � 720� . .
<br /> .. . TOTAL CONNECTION CHARGE� s
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<br /> a SEWER PERMIT FEE b
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<br /> � CATCH BASIN PERMIT FEE ���
<br /> ' TOTAL SEWER PERMIT FEES b
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<br /> � ..•p) MONTHLY SEWER CHARGES: TRUCK �
<br /> `-�� SEWER CQNSTRUCTION �ATERAL
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<br /> ,`� � �`� _ S�VVER SERVICE �
<br /> a ��APPROX. LOCATION OF SIDE SEWER OR TEE IN THE MAIN: �
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<br /> 7 {�t1" ,. DATE
<br /> " . .INFOCOMPILEDBY: DATE —
<br /> } APPROVAL: _---
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