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FO�i OFFICE USE ONLY <br /> ADDRESS ---- - --- -- ----__._._ _- ----- ----- - <br /> (11 BUILDINu PERMIT FEE g -------- - - ------ - <br /> (A) PLAN CHECK FEE ----------.. _ .----- - <br /> (2) PLUMBING ------ - --------- <br /> (3) MECHANICAL --- ----�- --- <br /> (4) STATE SURCHARG�S . ------- -- ---- <br />. (A) BUILDING CODE ------- -- --- ------ - <br /> (B) ENERGY COQE -------__------------ <br /> (5) DRIVEWAY F�FMIT ------ ----------__ . <br /> $ ---------- -=----- <br /> r}J <br /> (6) WATER SERVICE TO 9E PAID PRIOR TO �UILDING PER�d1T ISSUIINCE S __.���-_ ---. <br /> (A) TO BE DETERMINED BY BLDG. INSPECTOR__L�l___ INCI I �j (�a <br /> (B) EXIST. WATER .•ERVICE. APPLICATION NO. _____ ___.._.____ <br /> (7) STATUS OF SEWER CHARGES: <br /> BOIJD, DISTRICT __-FOOTAGE___-__ . __ <br /> N, 5. E. W <br /> SYSTEMS DEV�LOPMFNT <br /> � WATER —.�q�0 <br /> �/" SEWEFl _ _lP/�_— <br /> j TOTAL ORD. FEE ���� <br /> SEWFR CONNECTION CHARGES <br /> YEAR TRUNK $ <br /> LATERAL ----- --- <br /> TOTAL CONNECTION CHARGES $ __ __ I <br /> SFWER PEFiMiT FEE $ --24 __ <br /> Pu�lc ✓J;; �J ia 9 9� �� <br /> r <br /> ���� �� i� 9q <br /> 'J <br />