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DF� ..7friEldT OF COI✓ih1UMITY DiA'ELOP^.16 JzC?'iCC: <br />�� �� i1 I� 1� .' �, ��I`.� ( � ir� t � k. ?�..`i' I t I� �'� ] . . _� Li � q Y\- Y <br />ADDRf_S' — ---- - ----- -- ----- ---- I i l'I . __ _--- _ _ — <br />(1) E3UIL��ING PERMIT F[[ � <br />(A) PLAP: CHECK FEE � <br />(7) PLUMBINC <br />(3� A4ECHANICAL <br />(�4) WATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT ISSUANC[ <br />(A) TO BE DETERMINED dY DLDG INSPECTOR ._ INt l{ <br />(B) EXIST. WATER SERVICE, APPLICATION NO. ___ <br />(C1 �PPROX. I.OG1ll�1N -- - - _ - - - _ _ ___ _ — <br />— ---- — ---- CHART ._ _ __ _ _ <br />(5) DRIVE1h'AY N[ili1�{I� l(� I;I_ I'i',II) PRlnl: 1���) ii�,Jllli;;,:(� Pf 1:��.tll I'�� <br />_. <br />�Ui�NC.� --_. I���i-i ��r�'� i�,.. � i �� � i_. <br />(J) SIATUS OI" JLWFR CFIP,RC�I S. <br />130tiD __DISI'?ICI� <br />NO�I:S <br />i O:�I,?��1 _ <br />�� � , , <br />;���VER CONNEC�fIUi� CI i;`�RGi `� <br />YEAR TRl'-, ;. <br />I_ATERAL <br />TOTAL CONNECTION CHARCES <br />SEWER PERMIT FEE <br />CATCH BASIN PERMIT FEE <br />IC)l,'�l _�.`' i�..',I� <br />(;�l h;iOl�l �f II_`i Si:A�VcK C. f li;f;�.��, . <br />SEWER CON5T1 ,! � i i�_����' <br />i ,, , <br />LATEKAL <br />SFWER SERVICE <br />'',i'PRO;�. LO��;\TION OF SIDE SEWER OR TEE IN THE MAIN: <br />I ��! FO COMPI LE D BY: <br />�,; ,�.. <br />.` <br />S <br />� <br />CHART <br />DATE _ — <br />� • 1 : _ -- _ -- <br />