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TYPE OF WORg � rte� c.o�acno� Qnea� Cl�«m xoo� O� ��' �a � L7 �
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Tppe of Co� I IF III IV 'Y A B � o��
Oc�ey Gm�►: A B B F H I M g S II PaWECT COST ALUE #
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I heoeby oadiy ma I�e � iaro�ati� aa this appliuoog,r�idk s�o a�euac afmy lmowie�p�e uoe �dt oam.+cc 1 a�u «sadj. mati am ffie ow�oer or �ho�ea ag� �Or tLe
abo�ve-mUUi�ne mpetty and thst [�.tian aoo&� tn �� st�e �d bc� hws md w�l ptoceed en aoDOrdenoe wi8� sub�e�d pl�. I aa awa�e �at the baHding
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Peimit Valuation Pazk Stippart Fee # s
Pe[init Fee t SAC # S
Plan Check Fee S �iVs�er Metrr S"�e 5/8"; I"; E
State Surc�►arge S P�me R� �
Penstcy S Sewerl9vatterr Caome� Fee # �
Plumbing PermitFee ; W� Tawer Fee # S
Merhanicat Pecmit F� S
Bu�dda Depo�it S
SeR+er � Water Pamit Fee S � _
Gas Fireplaoe Pennit F� S TO'PAL DUE S
11dsA�ioaBeca�sY��Pe��vLma�e� Paid - ' No. '
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This is � oati� t� tue nqo�t � arc above app�ion wa ��ow� is ffi sorot�i�oe wim tbe �jr Zon�g O�m� mi maY P� ffi reqoa�ed. 17tia aoc�moenc
whea si�od yy the C�y Pl�a o� a�Y ' a£Tsx►� caa�li�e aod a�vs ��o wmmeooe. Be�Oe a�cepaorY+ a Ca�iCaoe of Ooa�y moat be
issaed.