HomeMy WebLinkAbout22-5012City of Zephyrhills
5335 Eighth Street
Zephyrhills, FL 33542BNR-005012-2022
Phone: (813) 780-0020
Fax: (813) 780-0021
Issue date: 11t03/2022
Permit Building (Residential)
6782 Ripple Pond Lp 04 26 21 0140 00100 0110
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Name: LENNAR HOMES LLC-OWNER Permit Type: Building New (Residential) Contractor: LENNAR HOMES LLC
Class of Work: Townhome
Address: 4600 W Cypress St 200 Building Valuation: $211,560.00
TAMPA, FL 33607 Electrical Valuation: $31,734.00
Phone: (813) 574-5700 Mechanical Valuation: $14,809.20 -- r
Plumbing Valuation: $21,156.00 AA
Total Valuation: $279,259.20
Total Fees: $13,575.45�
Amount Paid: $13,575.45
Date Paid: 11/3/2022 10:05:36AM
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CONSTRUCTION TOWNHOME 1400 SO FT AS
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Electrical Permit Fee $198.67 Transportation Impact Fee - City $34,80
Plumbing Valuation Fee $0,00 Mechanical Plan Review Fee $0.00
Plumbing Permit Fee $145.78 Building Plan Review Fee $180.00
Public Safety Impact Fee -Admin $26.35 Building Permit Fee $1,097.80
Transportation Impact Fee $3,445.20 Park Impact Fee - Single Family/Townhome $769.56
Electrical Plan Review Fee $0.00 Address Fee $30.00
Water Connection Residential Fee $1,010.00 Fire Wall/Smoke Wall Inspection $15,00
Public Safety Impact Fee -Police $254.00 Driveway Fee $45,00
School Impact Fee - Single Family $3,353.00 SIF 1 percent Fee $33.53
3/4 Water Meter Residential Connection Fee $732.71 Sewer Connection Residential Fee $2,090.00
Mechanical Permit Fee $114.05
EINSPECTION FEES: (c) With respect to Reinspection fees will comply with Florida Statute 553.80(2)(c) the
local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
first reinspection, whichever is greater, for each subsequent reinspection.
Notice: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that
may be found in the public records of this county, and there may be additional permit required from other governmental
entities such as water management, state agencies or federal agencies.
"Warning to owner: Your failure to record a notice of commencement may result in your paying twice for
improvements to your property. If you intend to obtain financing, consult with your lender or an attorney
before recording your notice of commencement,"
Complete Plans, Specifications add fee Must Accompany Application. All work shall be performed in
accordance with City Codes and Ordinances. NO OCCUPANCY BEFORE G.O.
NO OCCUPANCY BEFORE C.O.
I IIQL
CONTRACTOR SIGNATURE PE IT OFFICE
4
INSPECTIONPERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021
Building Department
Date Received Phone Contact for Permitting 908 770 7763
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11 1 1 1 1
Owner's Name CAL HEARTHSTONE LOT OPTION POOL 03 L P Owner Phone Number 813•574.5700
Owner's Address 1 23975 Park Sorrento, Ste. 220, Calabasas, CA 91302 Owner Phone Number
Fee Simple Titleholder Name N/A Owner Phone Number
Fee Simple Titleholder Address N/A
JOB ADDRESS 67$2 Ripple Pond Loop LOT # A011
SUBDIVISION Abbott Square PARCEL ID# 04-26-21-0140-00100-0110
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED NEW CONSTR H ADD/ALT SIGN DEMOLISH
P INSTALL REPAIR
PROPOSED USE 0 SFR COMM OTHER
TYPE OF CONSTRUCTION 10 BLOCK Q FRAME STEEL
DESCRIPTION OF WORK Multi -family / Screen Enclosure / Fence
BUILDING SIZE U/R IF 1763 SO FOOTAGE 140® HEIGHT 18'
_ BUILDING $ 2115E VALUATION OF TOTAL CONSTRUCTION
b(iELECTRICAL 31734 PROGRESSENERGY W.R.E.C.
::1 AMP SERVICE
PLUMBING $ 21156
MECHANICAL $ 14809.2 VALUATION OF MECHANICAL INSTALLATION
GAS 10 ROOFING SPECIALTY = OTHER
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA YES Do
BUILDER COMPANY Lermar Homes, LLC
SIGNATURE REGISTERED Y ( N FEE CURREN
Address 4301 W Boy Scout Blvd Suite 600 Tampa, FL 33607 License # CGC1518166
ELECTRICIAN COMPANY Edmonson Electric, Inc.
SIGNATURE REGISTERED Y / N FEE CURREN Y / N
Address License# EC13005408
PLUMBER COMPANY Bayonet Plumbing, Heating & AC, Inc
SIGNATURE REGISTERED YIN FEE CURREN L — . I N
Address License # I CFC042998
MECHANICAL COMPANY Bayonet Plumbing, Heating & AC, Inc
SIGNATURE REGISTERED Y / N FEE CURREN Y / N
Address License # I CAC058062
OTHER COMPANY C Sterling Quality Roofing, Inc
SIGNATURE REGISTERED Y / N�_J FEE CURREN Y ( N
Address License # 1 CCC057991
�01l1��111�1�tE��'11111B�1t���1l9IQ�itl�it1111111��i1�9s611i01111e11
RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction,
Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans wl Silt Fence installed,
Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisions/large projects
COMMERCIAL Attach (2) complete sets of Building Plans plus a Life Safety Page; (1) set of Energy Forms. R-O-W Permit for new construction.
Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans wl Silt Fence installed,
Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet compliance
SIGN PERMIT Attach (2) sets of Engineered Plans.
****PROPERTY SURVEY required for all NEW construction.
Directions:
Fill out application completely.
Owner & Contractor sign back of application, notarized
If over $2500, a Notice of Commencement is required. (A/C upgrades over $7500)
** Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (copy of contract required)
Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage)
Driveways -Not over Counter if on public roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the
contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation
under state law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for the
11 -W 110 IN
10111MM, MINIM; WAIME"
FLORIDA JURAT (F.S. 117.03)
OWNER OR AGENT -;M
Subscribed and sworn -o (or affirmed) before me this
71261 022 by Christopher Smith
Who is/are personally known to me or
as identification.
Notary Public
Commission No. GG 296057
Subscribed and sworn to (or affirmed) before me this
7126/2022 -- byChristopher Smith
Who is/are personally known to me or has/have produced
as identification.
Commission No
Notary Public
ti
Permit
Date Permittecl
Builder Name/Owner Name _
Control #
County Parcel No. G L1
L7 / ( SubDiv: r
Address/Location
Classification/Type of Use �!
-
TRANSPORTATION IMPACT FEE Rate:
Sq. Ft Unit:
Exempt 0 Yes 0 No How Determined
Impact Fee Amount i" Zone
No. TAZ:
SCHOOL IMPACT FEE
Account (056) Single -Family Detached House
Amount $ `
(057) Mobile Home
(058) Either Residential
(123) Collection Fee
Exempt =Yes = No How Determined -
PARRS AND RECREATION FEE
Land Account Land Credit Land Total
Recreation Account Recreation Credit Recreation Total
Zone Total Amount
Exempt =Yes =No How Determined
LIBRARY FEE
Land Account Land Credit Land Total
Facility Account Facility Credit Facility Total
Exempt Yes No How Determined Total Amount
RESOURCE FEE ERU
Prepared By Checked By
O CERTIFICATE OF OCCUPANY WILL RE ISSUED OR FINAL INSPECTION
PERFORMED UNTIL THE TOTAL AMOUNTS LISTER HAVE
BEEN PAID AND RECEIPTED FOR BY A CENTRAL PERMITTING OFFICE OF PASCO COUNTY
ACKNOWLEDGEMENT BELOW DOES NOT IMPLY ACCEPTANCE OF CONCURRENCE, BUT SIMPLY REECEIPT OF A COPY OF THIS
FORM, PLACING THE BUILDING OWNER ON NOTICE OF THIS ASSESSMENT AND THE CONDITIONS OF PAYMENT FOR SAME.
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Notice to Building Official of
Use of Private Provider
Effective January 20, 2003
Project Name: 6782 RIPPLE POND LOOP
Parcel Tax ID: 04-26-21-0140-00100-0110
Services to be provided: Plans Review X Inspections
Note: If the notice applies to either private plan review or private inspection services the Building
Official may require, at his or her discretion, the private provider be used for both services pursuant to
Section 553.791(2) Florida Statute.
the fee
owner, affirm I have entered into a contract with the Private Provider indicated below to conduct the services
indicated above.
Private Provider Finn:
Private Provider. DESPA ANNE KLAHP
Address: 747 SW 2ND AVE- SUITE 170,301,357,& 358, GAINESVILLE, FL 32601
Telephone: 813-376-3088 Fax: N/A
Email Address (Optional): deb@virtualreviewassist.com
Florida License, Registration or Certificate #: (LIC # BU1967/ PX2300/ BN4615)
Z:)
I have elected to use one or more private providers to provide building code plans review and/or inspection
services on the building that is the subject of the enclosed permit application, as authorized by s. 553.791, Florida
Statutes. I understand that the local building official may not review the plans submitted or perform the required
building inspections to determine compliance with the applicable codes, except to the extent specified in said law.
Instead, plans review and/or required building inspections will be performed by licensed or certified personnel
identified in the, application. The law requires minimum insurance requirements for such personnel, but I
understand that I may require more insurance to protect my interests. By executing this form, I acknowledge that I
have made inquiry regarding the competence of the licensed or certified personnel and the level of their insurance
and am satisfied that my interests are adequately protected. I agree to indemnify, defend, and hold harmless the
local government, the local building official, and their building code enforcement personnel from any and all
claims arising from my use of these licensed or certified personnel to perform building code inspection services
with respect to the building that is the subject of the enclosed permit application.
I understand the Building Official retains authority to review plans, make required inspections, and enforce the
applicable codes within his or her charge pursuant to the standards established by s. 553,791, Florida Statutes. If I
make any changes to the listed private providers or the services to be provided by those private providers, I shall,
within I business day after any change, update this notice to reflect such changes. The building plans review and/or
inspection services provided by the private provider is limited to building code compliance and does not include
review for fire code, land use, environmental or other codes.
The following attachments are provided as required:
1. Qualification statements and/or resumes of the private provider and all duly authorized representatives.
2, Proof of insurance for professional and comprehensive liability in the amount of $1 million per
occurrence relating to all services performed as a private provider, including tail coverage for a minimum
of 5 years subsequent to the performance of building code inspection services.
11MEM
(signature)
Print
Name:
Address:
Telephone
No.:
Please use appropriate notary block.
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
Individual
Before me, this day of
,20_, personally
appeared
who executed the foregoing instrument,
and acknowledged before me that same
was executed for the purposes therein
expressed.
Corporation
LENNAR HOMES, LLC
Print Corporation Name
By: . .. .....
(signature)
Print
Nam, Christopher Smith
its: Authorized Aaent
Address: 700 NW 107th- �v
Miami, FL 33172
Telephone
No. 813-574-5700
Corporation
Before me, this 22ND day of
MAY 2o_22,
personally appeared
of
Lennar Homes, LLC -,a
-corporation, on
behalf of the state corporation, who
executed the foregoing instrument and
acknowledged before me that same was
executed for the purposes therein
expressed.
ME=
Print Partnership Name
0
(signature)
Print
Name:
Address:
Telephone
No.:
Partnership
Before me, this day
Of 20_,
personally appeared
partner/agent on behalf of
a partnership, who executed the
foregoing instrument and
acknowledged before me that same
was executed for the purposes therein
expressed.
Personally known X ;or Produced identi cation Type of identification produced
SignatureofNotl !M�A Print Name ASHLEE CALLAHAN
Notary Public Stamp:
ASHLEE CALLAkX N
State of FloridaCommission Expires: jqokary public
ML GG 244456
NOVEMBER 30, 2022 Corm. EXPJ(05 Nov 10, 2022
khrDLSh tq5tjonDI Notary Alm...
Page 2 of 2
Block
FOLIO
FIRE MARSHAL #01 -
Reauired Permits
EXAMINER:DATE: 8/3/2022
Debra s VX2304
Building
Q Inspection Only
Plumbing
❑ Inspection Only
IV Mechanical
[:1 Inspection Only
IV Electrical Amp
❑ Ins ection Only
Roof
❑ Gas
❑ Medical Gas
❑ Fire Sprinklers
Q On Site Piping
Q Fire Line
❑ Irrigation
Q Fire Alarm
Q Potable Backflow Assembly
❑ Fire Line Backflow Preventer
❑ Irrigation Backflow Assembly
❑ Demolition
❑ Walk-in Cooler
Q Refrigeration
❑ Hood
Ansul
❑ Fence/Wall
❑ Grease Trap
❑ Other
Other
Type Construction:
I V_B
Risk Category:
Occupancy Load
ancy Classification:
Factory
Residential 12-3
Assembly------�
Hazardous
Q=Storage
Business ay Care/Educational
Institutional ❑Mercantile
i0 Utility
Building Use: Single Family Townhouse l Alteration 10Level I 'Level 2 Q Level
1,6 New Construction ❑ Interior Finish ❑ Interior Remodel ❑ Exterior Remodel ❑ Addition ❑ Revision
Overall Size:
26-8 x 71
Number of Stories:
1
Total Sq. Ft.:
1763
Living Area: 1400
Covered Area:
363
# of Bedrooms: 2
# of Baths: 2
Cost per square foot:
Estimated Value:
Roof Type: ® Shingle
❑Tile ❑ Built-up
❑ Metal Q Other Squares: 20
Zoning:
Wi orne Debris:
❑Inside
Outside
Energy Code:
405-2020
Flood Zone: X
Base Flood Elevation:
Finish Floor Elevation:
Hydrostatic Vents? QYes ,No
Sq. Ft. Enclosed Space Below BFE:
# of Vents:
Size of Vents:
Total Sq. In. Permanent Openings
d Central A/C
El Gas A/C
® Heat Pump
El Gas Heat
El Window A/C
0 Electric Heat
Sanitary Sewer
Storm Sewer Catch Basins
Potable Water
Under round Fire Line
I . m
Front Rear Left Right
❑✓ As per Approved Site Flan
Comments:
VR//\
VIRTUAL REVIEW ASSIST
Private Provider
Plan Compliance Affidavit
Private Provider Finn: Virtual Review Assist, Inc.
Private Provider: Debra Anne Klahr, BU 1967
Address: 747 Southwest 2,d Avenue
Gainesville, FL 32601
Phone: 813-391-2959
Email: IUC'(r�vii-tualreviewassist.com
Project: New SFT 6 unit
Address(s): Lots 7,8,9,10,11,12 Block I Ripple Pond Loop/ Abbott Sq
ott Sq
I hereby certify that to the best of my knowledge and belief the plans submitted were reviewed for and
are in compliance with the Florida Building Code and all local amendments to the Florida Building
Code by the following affiant, who is duly authorized to perform plans review pursuant to Section
553.791, Florida Statute and holds the appropriate license or certificate:
Name: Debra Anne Klabr
Plan Sheets: 1,2,3,4,5,6,7,8,9,10.1,LI,FP1,SN,SNI,S3,S4,S5, SS, Dl,WP,
PAI.0,PAI.1,PAI.2,PAI.3,SHI.0,SHI.1,SHI.2,SHI.3,SHI.4,SHI.5
Florida License/Registration/Certification #(s) and description:
FS468 Certified Standard Plans Examiner
License #: PX2300
I/ V
Signature of Reviewer:
SWORN AND SUBSCRIBED before me by Debra Anne Klahr
being personally c k, )wn to me or having produced as identification
Z�Ql
-A- and who being fully sworn and cautioned, state that the
Jf
aing is truecprrect t the best of his/her knowledge or belief.
e of Not Print Name
commission expires:4rt
APubSHLEE ' rAi AHo`AN
Not-,ry li C��ite Fiorica
mmn cossiop - QG 244456
or MV Comm. Expires Nov 301 2022
BGr"Iled througil National Notary Assn.
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DESCRIPTION;- LOTS 7-12, BLOCK 1, ABBOTT SOUARE PHASE IA SITE PLAN SEC. 4, TWP. 26 S, RNG 21 E.
ACCORDING TO THE PLAT THEREOF, RECORDED IN PLAT BOOK — PASCO COUNTY, FLORIDA
PAGE — OF THE PUBLIC RECORDS OF PASCO COUNTY, FLORIDA (NOT A SURVEY) (ABBOTT SQUARE)
PROPOSED ELEVATIONS AND GRADING
SHOWN HEREON ARETAKEN FORM THE
ENGINEERING PLANS OF
'ABBOTT SOUARE RESIDENTIAL-. PREPARED
BY 'WRA' PROVIDED BY CLIENT
his SITE PLAN Prepared for and Certified To:
Lennar Homes
ALL =ELEVATK)NS REFERENCED NORTH
To NORTH AMERICAN
VERTICAL
DATUM
.0
ERTICAL DATUM OF 1988
INAVET 88)
Scale: 1'= 20' 0
<
LL
.9 z
TW- TOP OF WALL a
BW- BASE OF WALL
LD
2- OAK 62
— T0.00'PUBLIC UT[LITYEASEMENT � C6
LEGEND:
------ 0-- PROPOSED DRAINAGE FLOW
(00.001 - PROPOSED GRADE
E-MOO - EXISTING GRADE
NOTES:
LOT GRADING TYPE - A
PROPOSED PAD ELEVATION - 98,40
FROM SET BACK - 20'
SIDE SET RACK - 7.5
SIDE SET BACK (CORNER LOT) - 15'
REAR SETBACK - 15'
LOT -_2Q235_SO. FT.
LIVING AREA -_a63LSQ, FT.
PORCH _J21__SCL FT.
GARAGE -JAUSQ. FT,
COVERED LANAI -_kJ2SQ. FT,
PATIO --N4&---SO. FT,
POOLAREA -_N/A___SCL FT.
CONC. DRIVE -AJJB__SQ. FT.
A/C & CONC PAD -_W_SCL FT,
SIDEWALK -_5fJZ____SCL FT.
LOT SOD -_N4&___SCL FT,
SOD ®NIA
So
. FT.
I LT OCCUPIED --3---
AREA TO IRRIGATE -_311— %
PROPOSED:
MINIMUM FLOOR ELEVATIONS:
LIVING AREA: 99.07'
GARAGE AREA
ELEVATIONS REFERENCED TO
NORTH AMERICAN VERTICAL
DATUM OF 1988
SURVEY ABBIREVATIONS
Af - ARC LENGTH 101 - MED
V�- AM ME- DRAINAGE EASEMENT
ALta�� ELORaEV-M-EVATION
WE: RASE ROOD ELEVATION EM - ED" OF PAVEMEW
W RENOTNIAM ESMT-EASEMENT
C_ o"'I, F/C - FENCE CORNER
IQ -CALCULATED FDA - FOUND CONCRETE
, _ CEWITRUNIE MONMENT
aF-CHAINLMFENCE Pip FOUND MOO PIPE
ChM-:COMUGATE"FTAL PIP MR FULM IRON ROD C.L
CCU.`W FN&D - FOUND MAIL & DISK
-cw -CONCRETE FOP - FOUND OPEN PIPE
qs - CONCRETE SIAS
NOTE: ENTRY WALKS ARE 3.0- CONCRETE
A4ARENT FLOOD HAZARD ZONE:')' COMMUNITY NO. 120235
C/S-A/C UNITS ARE 3.ZX3.2'
(MAP NUMBER 12101
C-0289-F) EFFECTIVE DATE: 09/26/2014
WV-INVERT-INVERTLE
La UC845M BUT
PC - PW OF CURVE
KC - MW OF COMPOUND CUM
(RI -RECORD
TING - RANGE
LE - LANDSCAPE EASENIMIT
PCP- pSMV4CNT CONTROL PONT
TITS - M ROAD SMM
LFE - LOWEST FLOOR ELEVATION P/E - POOL EOUPW04T
W-RPGHTOFWAY
LS-UCVasFDsuRVEYoR
PG -PAGE
PI-POO4TETSKHON
SEC SECTION
SEC -SECTION
SNOSETNALMDOSK
M MASE�
'C�XTMC�UCTTON
PX -fkWXR KALON
U1#8103
sist-F
NCF - NO COMER FOUND
O/A-OVERALL
Poe-Po;NtOF8EGNNflvG
TE=RODU348183
TOM BENCHMARK
OHW -OVERHEAD LVIREISI
poC - POW OF COWMNCM4ENT
TOO -TOP Of HANK
OR, -OFFICIAL RECORDS
PoL - POINT ON L94E
PRC - PONT OF REVERSE CURVE
TWP-TOWNsw
UE - UTILITY EASEMENT
JPJ -PLAT
an -PT ATrmKI
PW - PWAANENT REFERENCE MONL"
VF - VINYL FENCE
VINYLFENCE
WOOD FENCE
CHAJN UNK FENCE
ALUMINUM FENCE
-
JOB #5 164
0
SURVIVOWS NOTES:
1.) Current title information on the subject PrOPCI'ly' had not been
furnished to Initial Point Land Surveying LLC. at the time of this
SITE PLAN
2.) This sketch was prepared without the benefit of a title search.
No instruments of record reflecting Ownership, easements or
righft-of-way were furnished to the undersigned unless otherwise
shown hereon.
3.) Roads, walks, and other similar items shown hereon were taker
fr7 4n�glrn q plans and are subjectto survey
)S = does not reflect no determine Ownership.
6.) This SITE PLAN is subject to matters shown on the Plat of
(z
This certifies that h described
property5wUW""n`*"'S Ilion and
rneets ice for
SUrWe t Land
Sury h
5 5 472 in S
P ection
1708 Water Oak Drive
Tarpon Springs, FkiWa
Phone: 17271-831-1990
FloddaPI.S71230grnaft. m,�,
LBO 8183
Date of Site [-an: —2 2
5,A 'L"' 2-8 ISITE
DWGAS-L7-12-BI-SITE
W' r
File:
411fe Drawn b . DJS
Checked byJH
REVISIONS
'ABBOTT SOUARE PHASE I A'
6.) Dimensions shown hereon are in feet and decimal portions
uey Date
ROF tIRVEYORA ow
thereof.
83
7.) Contractor and owner are to verify ail setbacks, building
dimensions, and layout shown hereon prior to any construction,
-
N OUT OR
and Immediately advise initial Point Land Surveying, LLC. of any
n.Fatl Failure willbe
hereon. Failure to do
deviation from Information shown hereon. Failure to do
SIGN
UCENS
Initial Point Land Surveying, LLC.
F,
t
Permit No. 01
Date Permitted 12
Builder Name/Owner Name / � t �r � Control k
County Parcel No.?I��? a SubDiY:-
`�
Address/location
Classification/Type of Use
TRANSPORTATION IMPACT FEE Rate: Sq. Ft Unit:
Exempt 0 Yes No How Determined
Impact Fee Amount _$ T Zone No. TA2;
SCHOOL IMPACT FEE
Account (056) Single -Family Detached House Amount $
(057) Mobile Home
(058) Other Residential
(123) Collection Fee
Exempt = Yes = No How Determined_
!�11"M.�M.1� ;
Land Account Land Credit Land Total
Recreation Account Recreation Credit Recreation Total
Zone Total Amount $
Exempt =Yes = No How Determined
LIBRARY FEE
Land Account Land Credit Land Total
Facility Account Facility Credit Facility Total
Exempt Yes No How Determined Total Amount __
RESOURCE FEE ERU
Total Amount
Prepared By Checked By
CERTIFICATE OF OCCUPANY WILL RE ISSUED OR FINAL INSPECTION
PERFORMED UNTIL THE TOTAL AMOUNTS LISTED HAVE
BEEN PAID AND RECEIPTED FOR BY A CENTRAL PERMITTING OFFICE OF PASCO COUNTY
ACKNOWLEDGEMENT BELOW DOES NOT IMPLY ACCEPTANCE OF CONCURRENCE, BUT SIMPLY REECEIPT OF A COPY OF THIS
FORM, PLACING THE BUILDING OWNER ON NOTICE OF THIS ASSESSMENT AND THE CONDITIONS OF PAYMENT FOR SAME.
N
RECEIPT NO DATE — ___ _ BY