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MIMIC DEPAR11412M <br />BUIIrlIK7 P004IT I11r01PU1'I'ION <br />1) ISUIII)IbIG I'CI,4IT T•7y _.�4 � r"' <br />(A) PI1.1I ClU I L6 <br />2) PIlR4Bltr, <br />3) MM- IANICAr. <br />4) SOATER SFrCvICF TO BF PAID PRIOR TO BUuDIt4G PD04IT ISSUANCE <br />(A) TO BE DIMIC411n) BY PIM INSPECTOR _-,,_,' INCR <br />(B) FRIST. WATER SERVICE, APPLICATION 110. <br />(C) APPA)V. LOCATION <br />Ci vm <br />5) DRIM-1AY PER VT TO BE PI.ID PRIOR M BUILDING PUC-11T ISSUANCE <br />G='j FELT /1¢I)AI (TYPE) <br />'G) STATUS Or SLIMA CIi MES: <br />Bma) Z2Z Dimucr ' ' �FODTAGE <br />N, S, E, 11. <br />SUM CONNXrJON CHARGES <br />YEAR 7 TRUNK <br />Uffiru AL <br />TOTAL CONNL 10'i C-tltu GFS <br />Mot PIUMIT Fi'E <br />ChMl RA.SIN PE['MT FEE <br />70TAL SFkIER PLRMI'1' FEES <br />7) t1UVPIILY SUM CIDI=S: <br />SOG R OCNSTRUCTIM. <br />lATEmL <br />SI %Tt. i SERVICE <br />A5PIo1\ ILIGITIOV Or SIDE SUCH OR TL- IN MM MN: <br />INFO airlPlLM- BY: DATr <br />APPROVA-.: MTG <br />