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� � � ) � � � '' '� � %/ � � ��i= DATE /� �' �- ` - ,��% <br />ADDRESS �L L'/,C L:i /{ � i' ! c' — <br />� � � �' ��`�� / 7 <br />TYPE OF fiUILDING -�' ��� �� � � <br />c I � U. �i � <br />(1) BUILDING PEFiMIT FE� <br />(A) PLAN CHECK FEE <br />(2) tiVATER SERVICE TO BE PAID BEFORE SUILDING <br />PERMIT IS ISSUED �� <br />(A) TO BE DETERMI`IED BY PLBG. INS?.�INGH <br />�/ cUi�, <br />(B) EXISTING i,� INCH WATER SERVICE <br />� / <br />Ai�PLIGATION NO. ..•� � <br />(3) DRIVE�'VAY PERViIT TO AE PAID BEFORE BUILDING <br />PERMI IS ISSU�D FT, � D/W (T1PE) <br />�r �N�auce dFF �� Y - <br />. TOTAL �° <br />(4) STATUS OF SE�VER GHARGES: �1;��,'��� �'�'� <br />/Y <br />7 • <br />$ (D�.cJ tJ �'-� �� <br />gp� llISTRICT FOOTAGE <br />N,S,E,��' <br />SEWER CONNECTION CHARGES: /VDIVC <br />TRUNK � <br />LATERAL $ /v�/ve <br />TOTAL CONNECTION CHARGL � %VO/U� _ <br />SEWER PERIvIIT FEE�ClLYr�� � �'���'eTyJ � �V'Q� — <br />CATGH BASIN PER.�tIT FEE <br />TOTAL SE�VER PERMIT I'�ES <br />i5) hfON"_`IiLY' S�1Ve,R CHARGES: <br />iE�4r'R CONSTRUCTION: <br />TRUNK <br />LATERAL <br />SL:�V�R SERViC� <br />TOTAL <br />$ //1�0/YE` <br />� �� <br />$ %�0 /1%� <br />� /I�ON� <br />$ 2-Sd <br />LOC A'I'IOi\ OI' S' J� S��'� �R OR T`r_'I: IN TI-3� �fAINI�.�Y `�yE 1 a y� ��'J'T Q� <br />Cv�'�D 6�v J�,P����Y �' N aF s PQ�oz <br />,o,UEy � � a�L I�'�'�� INI'O COv1PILED BY� f <br />rThis total mcst be oaid beforc DATE �C -'� l r7� —_ <br />buil�iing permit is issued <br />