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1 <br /> BUILDING PERMIT INFORMATION <br /> ADDRE55 ��I � TLi�������11� � TYPE � � � <br /> (1j BUILDING f'ERMIT FEE �'6C)�B� •� S ' �''J <br /> (�) PLAN CHFCK FF.F �� <br /> (2) PLUh1F31NG — ' <br /> (3) MECHANICAL I <br /> (4) WATER SERVICE TO R[ PAID f'RIOR TO [3UILDING PFRMIT ISSU�NCF`� <br /> (A) TO BE DETFRMINED ftl BLDG INSPECTOR � INCH <br /> (R) EXIST ,___ W�TFR SERVICE, �PPLICATION NO. <br /> (C) APPROX IOIATION __— <br /> ------CIIART ------ — <br /> (5) DRIVLWAI' PFRMIT I'O flF PAID PRIOR 10 RIIILDING PERMIT IS <br /> SUANCE _— F[F1 _ _ DRIVfW/11' (IYPE) E _ <br /> S <br /> (7) STATLIS Of SEWER CHARGES. � <br /> BUND � C�ISTRICT FOOTAGE _ � <br /> N, S, � W <br /> NOTES <br /> sf�ac.. ur�c•�rY � <br /> o,eo ��7/- �gs� s'�4l8 <br /> yy fl s-�.7s- <br /> � � !S.?b"' � ��,��� • � � <br /> 2�9d.� � `� <br /> SEWER CONNE TION CHARGES <br /> YEAR TRUNK S � � � <br /> LATERAL �� • O v <br /> TOTAL CONNECTION CHARGES s ` G I ' �a <br /> SEWER PERMIT FEE S �D•�O <br /> CATCH BASIN PERMIT FEE �--�„--�— <br /> TOTAL SEWER PERMIT FEES b �fa/ 6�(J <br /> (7) MONTHLY SEWER CHARGES: <br /> � SE� J[R CONSTRUCTION TRUCK s <br /> LATERAL <br /> SEWER SERVICE <br /> APPROX LOCATION UF SIDE SEWER OR TEE IN THE MAIN: <br /> CHART <br /> INfO COMPILED BY: DATE <br /> APPROVAL. DATE .— <br /> 1/fl) <br /> r�i�t • ' <br />