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L LOCi,TION OF I~STALLA'I'ION <br /> <br />Parc~i 0~. <br /> <br />C:oss Su~IDirectioe$: 7~ <br /> <br />Zip: <br /> <br />Projr~ <br /> <br />WORK I5 5USPB~gD FOR 180 <br /> <br />~ ~ ~ Or offender ~ b~ore or upon <br /> <br /> ModularDwelllngServic~Fr. cdcr -- x $$2.00=S__2 <br />B. Services or Feeders (Does ne~ include b~anch Circuit% see se~6on D) <br /> Ir~tallatio% AReeagen or RelocaUon <br /> <br />C. Temporary 5ervlce~e~lers <br /> <br /> ~b ~dditLond branch ci~ait <br /> <br /> O. Minor [nstnllntlo~ <br /> <br />FEE~ <br /> Al. Enter total of fees from Sec. <br /> A2. Add State Surcharge (.05% x <br /> <br />B. F~r 30% oflln~ Al for [tim Review <br />C. Investigation Fee (if require~ <br /> <br />E. Addit~on~ PI~ Review <br /> m~nlmum o~e-h~f ho~) <br />F, ~s~oe ~ot w~eb no fee is speciflc~y i~cat~ <br /> ($6250~, ~mum ~ <br />G, Info,on Ou~ide No~ Business Ho~s, <br /> ($62.50a~, ~mmum ~o ~) <br />H. ~dusM~ P~t (~2.5~) <br /> <br />TOTAL AMOUNT DUE <br /> <br /> <br />