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<br /> �� � '.�+. 4 ��� �"'£ �•Y �' '
<br /> sl t�' �'R-�P �e- G►����`'� �t?� P�CS ON���,��t`i�`;�:
<br /> PE:RMIT TYPE A�'n Fl:1;: �NEW ❑ ADDITION ❑R�PAIR
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<br /> ln�ide Piumbing( !� fixtuRc ) Fee S_. On Site Septic System Fee S_�.sL�G_
<br /> W3tcr Metrr(Siz�� 1 F�•C � Water Well Fee S
<br /> Meter �
<br /> Mechanicgl Equipmrnt Fce S.� ,
<br /> Remote�
<br /> Municipal Wat�r Conn��rtion F:«. g I�fovin1¢/Lifting Buiidin� Fee S �
<br /> ❑Copper n _ Land Alt��ration fFxcavation. Fc� S 1od
<br /> Grading, Filiin�,etr.)
<br /> Municipal Stwer Cunnertian fr�• S
<br /> ❑ PVC ❑ Cast n Oth r: �-1 C-�S� �25�� Ftt 5.=...
<br /> 4tWCC SAC Cliargr Fec � Afterthe-fact Invrstigation Fec S�.,...
<br />�CKNOWLEDGEMENT TOTAL
<br /> Th�und�ni�nM h�hby �eknowMdp�ncelpt ot thl�Umlad
<br /> p.nslt, IneludlnR ��Vane� e/ W q�elal Infonn�tlon. �
<br /> anns. aw��tlau or rM��reni�nh wdtt�n �bow. Th� State SuRh�rr�tr' FCC s�.
<br /> ��rda+lp�ed und�nesnds �nA �s�+M under Mntltf� ot !�w •
<br /> th�t 1lJr Mrnit U �tzlefly UnUMd in �eop� to Ih� waelt,
<br /> sctivlV or 4nOrow�nw�t �MHNed: tA�t tl�b P�nelt doa �r �
<br /> net �nt �r wWoelb to do w�aek oe �etlWtlN r�0ulrlet Total Amount Paid to City FCC �-� ?
<br /> rp��te pnn�t �OProrals; and tl��t tl►M Mnnit doe� not
<br /> pyae wMo+lpr 10 Nolat� �nr p►oridon of �n� Clri
<br /> oedinane� or 3taM I�M,euH a ttN�tlon. A11 wotk d1�11 b�
<br /> aaa tn .a�ee eanvn�nc. r►IW ap cYtr oreln.n�w.buumaa
<br /> �oe.. .�aio� n..iw a.o.*a++.a� �anw�,, .pe .n.0 a This p�nnit is not valid unti! thc• proper fc� ic paid :�nc
<br /> .�s�� w a.n.�a�, .no.�•r� a .•�tlo� e. a. a�r. it is approved by an authorited City Officiai.
<br /> wh�n�ws w ad�r�d, tM und�etlp►�d � fo eorfret
<br /> �nf wo�t foued eo D� in Nol�tlow ot condidoe� ot
<br /> tRis O�nnl�
<br /> ignatu • f t SignutuR of City Official
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