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:, I IVi+ �J <br />ADDRESS___7 057 C <br />TYPE OF BUILDING S._ <br />it BUIILDI:.�, PERI,:IT FEE Z496GI(Dc-) <br />(A) PLAN CHECK FEE <br />2) \CATER. SERVICE TO BE PAID <br />PERM17 IS ISSUED <br />(A) TC BE DETERMLtiED BY PLPG. INSP. INCH <br />N <br />(B) EXIST. WATER S.:RCICF, APPL. NO. <br />(C) LCCATION ( �D_7_ � <br />n <br />(_'Q�CIiz,RT 07 / q <br />it DRI\'El':AY PERMIT TO BE PAID EIX it E E•L ::.MNri <br />PER\IIT 1S ISS. ED FT. PT(" ITYPEI <br />TOTAL <br />4) STATUS OF SEWER CHARGES: <br />POND .7� DISTRICT SS FOOTAGE <br />LANDSCAPE NOTES <br />SEICER CCNNECiIC% CHARGES: <br />TF.:'NE <br />LATERAL <br />TOTAL CC:<::ECTICN CHARGE <br />SEWER PERM17 FEE <br />CATCH BASIN PERMIT FEE <br />DATE <br />S (a Cl , O r. <br />S /a , so bae <br />Z7.0 0 <br />5 �lnS",ay <br />5 O, f1 <br />3�S • O ,-) <br />S so, c, o <br />c <br />I TOTAL SEICER PERMIT FEES S 20. U U <br />5) MONTHLY SERER CHARGES: <br />SERER CONSTRUCTION: <br />TRUNK $ ,a <br />LATERAL $ -7 5 <br />SEWER SERVICE: $ S U <br />LOCATICNIOF SIDE SEWER OR TEE IN THE MAIN: CHART r S <br />OF M N <br />INFO COMPILED BY: <br />•� Q-7 DATE S_- <br />REVIEW: ��--`_- DATE 5�9 �— <br />R FIC DIVISION <br />APPROVAL: C<- DATE <br />E 1 EE RING DEPARTMENTT <br />This total must be paid before building permit is issued. <br />(D 15I 00 <br />