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�� <br /> FOR OFFICE USE ONLY <br /> ADDRESS _ _ - <br /> (1) BUILDING PEiiMiT FEE $ <br /> (A) PLAN CHECK FEE <br /> (2) PLUMBING <br /> (3) MECHANICAL <br /> (4) STATE SURCHARGES <br /> (A) BUILDINC3 CODE <br /> (B) FNERGY CODE <br /> (5) ORIVEWAY PERMIT /� <br /> $ ��-�� <br /> (8! WATER SERVICE TO BE PAID PRIOR TO BUILDING PERMIT ISSUANCE 3 �Q� <br /> (A) TO BE DETERMINED B.' 2lD(3. INSPECTOR INCH <br /> (B) EXIST. -V�.4TER SFRVICL•.APPLICATION NO. _ <br /> (7) ;,TATUS OF SEWER CHARGES: <br /> 8,7ND __DISTRICT_ FOOTAGE <br /> N. S, E. W <br /> SYSTEMS DEVELOPMENT <br /> WATE P. �/�1�2 <br /> SEWtR (/D� I�� <br /> TOTAI.ORD. FEE y 7Z <br /> �' `•VER CONNECTION CHARGES <br /> 1� , �i__ �L TR� $ ���Q _ <br /> I.ATERAI. - <br /> TOTAL CONNECTION CHARGES $ _ .�30 = <br /> SEVJFR PERMIT FEE $ -_ 7� - ` + <br />