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BUIU)IldC Uk1'Nt11-11171' <br />1IUIIDIM, I'MflIT INC'OTOWrION <br />ADDR1i.;S4-9c) � L 'jR l�E. (�� TYPE <br />1) BUIU)ING I.1T54IT I7:Ti <br />(71) Pull CIII•X;Y, I'M. <br />2) Pla4BII•x; <br />3) MMtANICAL <br />4) WAITM SEMVICE TO PE PAID PRIOR '10 PUILDING Pi RmIT ISSUANCE - <br />(A) TO BE D13Mr—lI1MD IIY P r' INSPECTOR �> nal <br />(B) EXIST. WATER SERVICE, APPLICA ION NO. <br />(C) APPROX. IOCATION <br />CFIAI2T <br />5) DRIV Zr�Y PET ,!T'I' TO BE PAID PRIOR 1D BUILDING PER;•IIT ISSUANCE <br />— FEET i�,� ti '� D/W (TYPE) <br />'o) STATUS OF SE,%M CII•"+.f'ti:: <br />BUD-1 DISTRICT FOMGE <br />N, S, E, W. <br />NOTES <br />SE,,ER C NNECTION CHARGES <br />YPAR %g TRUNK <br />I. i4nm <br />70TAL COtvNDCi'ION CHARGES <br />1--k-r <br />It `:C• l D • Uii <br />SE; IR PERMIT FEE �X <br />CATai BASIN PERMIT FEE <br />n <br />1OTAL SWER PER,1I'T FEES $ Ci i <br />7) MMn]LY SE en CIIA=: <br />SEWER CONSTRXTICN: TR m $ <br />I1ff�RF1L <br />SEWER SERVICE c <br />APPIM LOCATION OF SIDE Sn'M OR TEE IN 7IIE MAIN: <br />• CIIAF.T <br />IWO M TILED BY: � OATE <br />APPROVAL: - DATC <br />