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� a 1 i <br /> � <br /> fBU1LDl �IG� L�E �I�v11T IP� FORM/��'i0 �1 I <br /> ADDRESS ' TVPESIr`!U(�G � I <br /> (1) BUILDING PERh1� ; FEE S�� �t� •�� g �p, d� <br /> ,A) PLAN CHECK FEE ��j.�'S <br /> (1) PLUM(31NG _ S�, I <br /> (3) MECHANICAL ^�(p , g"a I <br /> (4) WATER SERVICF TO RE PAID PRIOR TO BUILDING PfRMIT ICSUANCE COL7 �ED � <br /> (AJ TO BE DETERMINED 8Y BLDG INSPECTOR _ INCH <br /> (B) EXIST. WATER SERVICE, APPUCATION NO. <br /> (C) APPROX. LOCATION _. <br /> _ CH,1RT _ Ii <br /> (5) DRIVEWAY PERMIT TO B[ PAID PRIOR TO BUILDING PERMIT IS- � <br /> SU�NCE . FEET DRIVf_WAY(TYPE) 5� _ �Z�•� v I <br /> g _ ' <br /> (71 STATUS OF�FR CHARGES: I <br /> 80ND �� DISTRICT _ FOOTAGL <br /> �I, S, E, W <br /> NOTES <br /> l.���d �7��S � <br /> �z � � �79. Q� <br /> S�-u�-.� ��!_a� ' <br /> �$o°� <br /> SEWER CONNECTION CHARGES <br /> YEnR _ gZ _TRUNK � ��.�� I <br /> LATERAI_ <br /> TOTAL CONN�CTION CHARGES $ 3�c6�C� <br /> SEWER PERMIT FEE S 3O•�v <br /> CA7CH BnSIN PERMIT FF.F �" <br /> TOTAL SEWF.R PERMIT FFES $ _�.L�•� , <br /> (7) �.10NTHLY SEWER CH�RGES: I <br /> SEWER CONSTRUCTION TRUCK S I <br /> LATERAL i <br /> SEWER SERVICE � <br /> APPROX. LOCATION Of SIDF SEWER OR TEE IN THE MAIN: _ <br /> CHART ' <br /> INFO COMPILED BY: DATE <br /> APPROVAL: DATE <br /> ��Fl, <br />