HomeMy WebLinkAbout23-6091ty of
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5335 Eighth Street
Zephyrhills, FL 33542
BNB- 0 0 1-2 23
Phone: (813) 780-0020
Fax: (813) 780-0021
Issue Date: 0510212023
Permil T i i l Residential
77
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04 26 21 0160 02000 0030 36529 Camp Fire Terrace
,..777
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Name: LENNAR HOMES LLC Permit Type: Building New (Residential) Contractor: LENNAR HOMES LLC
Class of Work: Townhome
Address: 4301 W Boy Scout Blvd 600 Building Valuation: $250,320,00
TAMPA, FL 33607 Electrical Valuation: $37,548.00
522.40 17ti l l V i h ecancaauaon:
Phone. M$ ,
Plumbing Valuation: $25,032.00
Total Valuation: $330,422.40 am�
Total Fees: $14,333.47
Amount Paid: $14,333.47
Gate Paid: 5/2/2023 11:37:50AM
CONSTRUCT TOWNHOME 1634 SQ FT
Driveway Fee $45.00 Address Fee $30.00
School Impact Fee Single Family $3,353.00 Electrical Plan Review Fee $0.00
Mechanical Plan Review Fee $0.00 Electrical Permit Fee $227.74
314 Water Meter Residential Connection Fee $794.92 Mechanical Permit Fee $127.61
Water Connection Residential Fee $1,140.00 Transportation Impact Fee $3,445.20
Plumbing Valuation Fee $0.00 Public Safety Impact Fee -Police $254.00
Transportation Impact Fee - City $34.80 Public Safety Impact Fee -Admin $26.35
Fire Wall/Smoke Wall inspection $15,00 Building Permit Fee $1,291.60
Building Plan Review Fee $180.00 SIF 1 percent Fee $33.53
Sewer Connection Residential Fee $2,400.00 Plumbing Permit Fee $165.16
Park Impact Fee - Single Family/Townhome $769.56
EEI SPECT"IOS FEES: (c) With respect to Reinspection fees will comply with Florida Statute 553.80(2)(c) the
Kcal 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 commencements"
Complete Plans, Specifications add fee Must Accompany Application. All work shall be performed in
accordance with City Codes and Ordinances, NO OCCUPANCY BEFORE C.O.
NO OCCUPANCY BEFORE C.O.
TOR SIGNATURE PE IT OFFICE
813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021
Building Department
Date Received Phone Contact for Permittinj 908 770 7763
Owner's Name CAL HEARTHSTONE LOT OPTION POOL 03 L P Owner Phone Number 813.574.5700
23975 Park Sorrento, Ste. 22D; Calabasas, CA 91302 — m�
Owner's Address Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number
Fee Simple Titleholder Address NIA
JOB ADDRESS 36529 Camp direerraCe LOT # 2QQ
SUBDIVISION AbbOttSt�Uate� PARCELto# �4-26-21 Q16Q-0200d-tif)
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED NEW CONSTR ADD/ALT SIGN DEMOLISH
INSTALL REPAIR
PROPOSED USE SFR COMM OTHER
TYPE OF CONSTRUCTION BLOCK FRAME STEEL
DESCRIPTION OF WORK Mu14Ffamily i Screen Enclosure 1 Fence
BUILDING SIZE/ sF 2®86 SO FOOTAGE4 HEIGHT 28'
BUILDING $ 250320 VALUATION OF TOTAL CONSTRUCTION
ELECTRICAL $ 37548 PROGRESS ENERGY W.R.E.C.
�( AMP SERVICE
1*d (PLUMBING
MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION
722 4 t. µ EJ ......,...i3.
=GAS ROOFING SPECIALTY = OTHER
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA DYES DO
BUILDER -- COMPANY Lennnr lDomes„ LLC
SIGNATURE REGISTERED Y / N FEE CURREN Y / N
Address 430 qL Boy Scout Blvd Suite 600 Tampa, FL 33607 License # I C 'C:1518166
ELECTRICIAN COMPANY Edmonson Electric, Inc.
SIGNATURE r t _ REGISTERED Y/ N FEE CURREN Y 1
Address '-�-- �- License # EC13005408
PLUMBER COMPANY Bayonet Plumbing, Heating &� AC, Inc
SIGNATURE REGISTERED YIN FEE CURREN Y / N
Address License # �FC042998
MECHANICAL � COMPANY bayonet�Plumbing,Hea�fing&AC, Inc
SIGNATURE REGISTERED Y / N
Address License # CAC058062
OTHER COMPANY C Sterling Quality Roofing,�N��
SIGNATURE S REGISTERED Y / N� FEE CURREN Y
Address License #CC057991
Aii1111I8N91lE'BLi9Iiip11t99199lI.L.1..�9Liil9t1II0t!IIIBii111911E1B9i8�11
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 w/ Silt Fence installed,
Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisionsmarge 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 w/ 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
OWNER OR AGENT CONTRACTOR
Subscribed and sworn a (or affirmed} before me this Subscribed and sworn to (or affirmed) before me this
,1IM ozs by Christopher Smith sr211z021 -by Ghnstopher Smith
WMo is/are personal) kY nown to me orb Wt o is/are porsonally known to me or has/have produced
as identification. as identification.
Notary Public Notary Public
Commission 6296057 Commission No. 6 7
Stephanie Farmer Stephanie Farmer
Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped
i .. NIi Dy Gomm ' nt
�'xxptsasJtane,2Q23 tsian6,02&
,Q g " its fA1 t a Troy
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Notice to Building Official of
Use of Private Provider
Effective January 20, 2003
36529 Camp Fire Terrace
04-26-21-0160-02000-0030
Services to be provided:
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.
owner, affirm I have entered into a contract with the Private Provider indicated below to conduct the services
indicated above.
Private Provider Finn: VIRTUAL PEVIEW ASSIST, INC,
Private Provider- DEBRA ANNE KLAHR
Address: 747 SW 2ND AVE- SUITE 170,301,357,& 358, GAINE5VILLE, FL 32601
Telephone: 813-376-3088 Fax: N/A
Email Address (Optional): deb@virtualreviewassist.com
Florida License, Registration or Certificate M (LIC # BU1967/ PX2300/ BN4615)
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 goverimient, 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
i.
M
Tho following atta�Dbments are provided as required:
1 . Qualification statements atd/or resumes ofthe private provider and all duly. authorized Tepresentatives.
2, Proof of insurance for professidnatand comprehensi-vo I ab&it i y in,the.'amount of $1 million per
o cGurrenoe relating to all services performed as a private provider,'fficluding tail coverage fbT, a mitiraum,
of 5years subsequent to the perfpnua`nce.of building code inspection services.
Individual
(signature)
Print
Name:
Address'. _'
Telephone-,
Pleageuse appropriate notary block.
STATE of FLORIDA
COUNTY bF HILLSBOROUGH
ludyidnal
B 5.fo i D, m e., thi sqay Of
20�pbrsoually
appeared .
who ' DxDr,�att-,dthBforeg6ingin.str=' Biat,
and aDkn owl o dg t d before me that s are o
-was exepat�d for the, purposes therein
express;d.
qqrporation
Print CwpomtionNarnq
By:
Print
'game: Chr!8t oher Smith
its: Authorized ent
Address- 7 0 W 107th Ave.
Miami FL 33172
No. 9137574-5700
Corporation
Btfo.rolne,this 22ND day of
MAY 20-22
personally appeared
of
Lennar Homes LLC a
cox°por�'tiaxt, tin
bvhz1f oftiro -state rorpoTation, who
executed the foregoing istrmant and
aclan owle dg Dd before me that S amie was
exeoutDd for the putppsrslhamin
Partnership
By.
0
Address,- - ,
Telephone
OEM=
of 20,
personally appeared
p arfnexh�vnt onb 6lialf of
a partnership, who exe�outea the
fbregoin,g instrument and
aol�uowledgDa befm ine that same
Pasonallyknown X or Pro ducied. idertitcation- Type of idmtifloa.fimpToduced
r
Signature OfNotan sipa PrintNamie AS LEHE CALLAHAN
NotaxyPublic Stamp.;
ASHLEE CALLAHAN
$SION # NH 296980 Commission Expires; MYCOMMI
W EXPIRES: NoVeMber 30, 2026
COMMERCIAL
TRACKING #
FOLIO# -16529 CAMP FIRE TEP
BUILDING SERVICES DIVISION
BUILDING PERMIT DATA SHEET
FIRE MARSHAL #01 -
Reouired Permits
RESIDENTIAL,
DATE: 4/09/2023
EXAMINER: Debra Klahr PX230(
Building
Plumbing
Mechanical
El ectrical
■Inspection 0n1v
Ins ection OnI I
El Inspection On
Ins ection On
=--
ical Gas
El Fire Spr inklers
. . . . . . . . . . . . .
El On Site Piping
Ej Irrigation
E] Fire Alarm
El Potable Backflow Assembly
El Fire Line Rackflow Preventer
irrigationliackilow Assembly
El Demolition
Ova,
El Hood
IMMIMMM,
0 Other
M"MMIM
e Construction I Occupancy Load
aney Cla s—ification:
I Assembly
—Iusi
ness FDay Care/Educational
FaetoZ Hazardous Institutional Mercantile
Residential ial ity
Building Use- SINGLE FAMILY TOWNHOUSE Alteration [—Level I Level 2 Level 3
4f New Construction 0 Interior Finish El Interior Remodel Exterior Remodel Addition E] Revision
Overall Size: Number of Stories: Total Sq. FL:
18 X 63 2 2086
Living Area: 1634 Covered Area: 452 # of Bedrooms: 3
# of Baths: 2.5
Cost per square foot: Esflm�ated Value:
Roof T e: X Shin le Tile R Built-up Metal Other S uar13
es:
Zoning: Wirdtne Debris: Vi,2utside 40 Energy Code: 5-2020
s i d e
Flood Zone: X Base Flood Elevation: Finish Floor Elevation:
Hydrostatic Vents? M"Y s No Sq. Ft. Enclosed Space Below BEE: j
# of Vents: Size of Vents: Total Sq. in. Permanent Openings
5 C C R Window A/C
0 entral A/C X Rest Pump
El Gas A/C El Gas Heat Electric Heat
On Site iping
Sanitary Sewer for Sewer Catch Basins
Potable Water Under round Fire Line
Setbacks
Front Rear Left Right
As per Approved Site Plan
Comments:
X"
VA"i "N
M
IN
KENN
\/R/\
Private Provider
Private Provider Firm: Virtual Review Assist, Inc.
Private Provider: Debra Anne Klahr, BU1967
Address: 747 Southwest 2°d Avenue
Gainesville, FL 32601
Phone: 813-391-2959
Email: luccz°t�ralreviev sist.con
Project: New SFT
Address(s); 36,529 CAMP FIRE TERRACE
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 Mode 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 Klahr
Plan Sheets 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16, L1, SN, SNI, S3,S4,S5,S6, ST, SS, DI, 1, 2,WP2.1,
PAL0,PAI.1, PAI.2,PA1.3,PAI.4, SHI.0,SHI.I,SHI.2,SHI.3,SIII.4;SHI.5
Florida License/Registration/Certification #(s) and description:
FS468 Certified Standard Plans Examiner
License #: PX2300 _ '
Signature of Reviewer: g
f
SWORN AND SUBSCRIBED before me by Debra Anne Klahr
being personally known to me °, or having produced as identification
and who being fully sworn and cautioned, state that the
to egoin `, is true and correct to the best of his/her knowledge or belief.
i
�..w
.,. t
i eofNot ¢ Print Name
Notary Public: NOTARY STAMP BELOW My
commission expires:
DESCRIPTION: LOT 1-4, BLOCK 20, ABBOTT SQUARE PHASE 2, SITE PLAN SEC. 4, TWP. 26 S, RNG 21 E.
ACCORDING TO THE PLAT THEREOF, RECORDED IN PLAT BOOK
PASCO COUNTY, FLORIDA
PAGES_ OF THE PUBLIC RECORDS OF PASCO COUNTY, FLORIDA,
INOT A SURVEY)
(ABBOTT SQUARE PHASE 2)
This SITE PLAN Prepared for and Certified To
PROPOSED ELEVATIONS AND GRADING]
Lennar Homes
SHOWN HEREON ARE TAKEN
A KENFORMTHE
ENGINEERING PLANS OF is
I 'ABBOTT SQUARE RESIDENTIAL', PREPARED
i BY "WRA" PROVIDED BY CLIENT
ALL ELEVATIONS REFERENCED
TO NORTH AMERICAN
Scale: 1 20'
VERTICAL DATUM OF 1988
fNAVD 88)
TRACT "B-8"
(CDD) OPEN SPACE
N ST4904' IS fl-1 42.69 (PI`
CS E. (B)
�Tn EY��
PROPOSED
Z PROPOSED
% Hv','0R`k,,
Ho
!� ! STORY
PLAN 1532
-,TOWNHOME
El - rV TIT
'B PLAN 1624
ZF
GARADER
i� ELEV LF
4
8
GARAGE L
LOTS
LOT
ro LOT
BLOCK
BLOCK 20'
0
4BLOCK 20
70
63
10,0
Be 11
5 _CONE,_ WALK
ENTRY ENTRY
is
ILE) I0
icEb
_F1 �7_1.1kr�,71 0
A
-1- R�, L
2 7,7
PROPOSED
1 STORY
OWNHOME
PLAN 1624
ELEV "TH
GARAGE R
LOT 2 in
BLOCK 20 ' q
ENTRY
28 34 ID
iD
io
NA
1&0
Ci
Ci
PROPOSED
?STORY
ei
OWNHONIE
PLAN 53?
�TH
EL EV
GARAGE I.
LOT I
BLOCK 20
TO
ENTRYr\1_1
TRA T "B-7A*'
fI D 0
(CDD) PARKING AREA
I 13'(P)
2834 IF) C
27,7,
BASIS OF BEARING
!P)
NOTES:
CAMP FIRE TERRACE
TRACT "A"
LOT GRADING TYPE -A
(CDD) RIGHTHOF-WAY
PROPOSED PAD ELEVATION = 114.00
FRONT SET BACK = 20
LOT
= ROS3
SO, FT,
SIDE SET BACK- 7.5
LIVING AREA
= 2682
SO FT,
ENTRY
= 280
SO. FT.
SIDE SET BACK (CORNER LOT) = 10
GARAGE
= 484
SO, FT.
REAR SETBACK - IS
NOTE: ENTRY WALKS ARE 3,0 CONIC
COVERED LANAI
= 436
SO. FT,
C/S-A'C UNITS ARE 3,2 X3.2
PATIO
-
=_A6i_SO.
FT
PROPOSED:
10.00'PUBLIC UTILITY EASEMENT
POOL AREA
=_NA_SO.
FT.
MINIMUM FLOOR ELEVATIONS:
LEGEND:
CONC. DRIVE
A,`C & CONE PAD
990
-_�Q
SO. FT.
ITT -
LIVING AREA: 114,67'
SIDEWALK
SIDEWALK
= j-SOL
SO, FT,
GARAGE AREA:
PROPOSED DRAINAGE FLOW
SIDE YARD SWALE
FT,
ELEVATIONS REFERENCED TO
100,00) = PROPOSED GRADE
CONSERVATION AREA
FT.
NORTH AMERICAN VERTICAL
E-0e00 = EXISTING GRADE
LOT OCCUPIED
= 60
%
DATUM OF 1988
AREA TO IRRIGATE
= 40_%
APPARENT FLOOD HAZARD ZONE: X COMMUNITY NO. 120235
(MAP NUMBER 12 ICIC-0452-H EFFECTIVE DATE: 09/26/2014
SURVEY ABBREVATIONS
f
Al - AEO LINGTH
DIED
)DI-DEED
INV - INVERT
PC - DOW! .1 CUF11 - RECORD
FDI
LEGEND
A/C AIR CONCEDE.",
"D
LB-LICENSED BIASNESS
PCC - POINT OF COMPOUND CURVE KING - RANGE,
VINYL FENCE
N FENCE
_ "u"1F`.`E0WATI.N
11 LEV • ELEVATION
L F - LFNDSCAPF CASEMENT
POP - PrPMANENT CONTROL POidl RRTF - RAIL ROAD ADEL
M_ "cr, C
8FCAl
- BASE
.�R FOOD OF PAVEMENT
LFE -LOWEST FLOOR FLEVACON
11E - POOL EQUIPMEW R/W - RIGHT OF WAY
BID - BENTH MARK
C - CIROL
NJ T - EAOGC 1
F/C - FOW CORNER
LS-UCE SEDSURVEYORT
(M) - MEASURED
PG - PAGE SEC - SECTION
PI - POIN I OF INTERSECTON BRAD -SET NAL AND of FEE
E=-ASMFIALI
On FENCE
f I CAL UDLATED
- FOU'
DCM ND CONCRETE
- IT
FEES DRED ENID SECTION
PC -PARECER KALON HDR3181
ENT
CENTERLINE
C
CHF - CHAIN TENK
MOSSUM NT
NCF - NO COB ER FOUND
I - PROPER'Y LINE SIR - SCI 1/2-PON ROD I T30 8`13
CHAIN Lnu FENCE
CRIB - ol �
CoRRMG 1
_ FOU
FIR _ FOUND IRON PIPE
FIR NO iRON ROD
EPA - OVERD L
CHIP -OVERHEAD
- POINT
FOR I OF BEGINNiNG TFIER - TEMPORARY SENO I MARK
DOC - POINT OF COMMENCTMFNT
-.RIIK
CL
C C �6
C ONR� - (�INCRETF
Do
FEVED- UN NAtL&DISK
POREO)
OR - OFFICIAL RECORDS
TOO - TOP 01' BANK
POI - POINT ON FINE TOWNRHIP
ALUM NUM PENCE
C" - CONCRETE SLAB
FOP FOUND OPEN PIPE
ta -TEAT
PRC � *DINT OF REVERSE CURVE. U E - UTILITY EASEMENT
[2j�3- COVERED
--EST - CLEAR SIGHT FEEANDE E
G, -OUND PINCHED RIP,
PC -PLAT PLAT BOOK
PRe `T1eaANENr REFE
REFERENCE MONUMENT VF - KIND FENCE,
JOB #6065
SURVEYOR'S NOTES:
SURVEYORS CERTIFICATE
1708 Water Oak Drive
5a-
oorsiteplam 11-4-22
1.) Cui rent title information
furnished to Initial Point
on the subject property
Land Surveying, LLC, at the
had not been
This certifies that Sic f the hereon described
time of this property a FEE upewdic'n and
Tar Springs, Florida
Phone: (727)-831-1990
IWG ASVG 18 L 1 4 PL20 SITE
SITE PLAN
meets to C e S Practice for
rioridaPLS7 t 231Vqmajtc
m
2,) This sketch was prepared
without the benefit Of a title search.
Surveys Oa to of Land
LB# 8183
No instruments of record reflecting ownership, easements or S Ne I
7LJe_ rights -of -way were furnished to the undersigned, unless otherwise aAW ned
shown hereon. He", by DJ8 3,) Roads, walks, and other similar items shown hereon were taken S at
u t S c ion 47 rtley
Date- �(kf 11.28.
?EVISIONS 4t This SITE PLAN r I In
-necked by.,JH from engineering plans and are subject to survey. H
vr�PPwa
does not reflect nor determine Ownership. ,II "
5,) This SITE PLAN I, subject to matters shown on the Plat of Jf5'00' Es
"ABBOTT SQUARE PHASE 2 -------------
6.) Dimensions shown hereon are In feet and decimal portions Jeff
BID ,k-WR AND 10
thereof,
7.)Contractor and ownei are to verify all setbacks, building PPEI
dimensions, and layout shown hereon prior to any construction, NOT VALID WITHOUT THE ORIGINAL
and immediately advise Initial Point Land Surveying, LLC. of any SIGNATURE AND SEAL OF A FLORIDA 1�1
devi.a,hohfrom information shown hereon, Failure to do so will be LICENSED SURVEYOR AND MAPPER Initial Point Land Surveying, LLC.
f
1
I
I
112.70
I
I
114.43
I
i s
j I
I �
115.22
f
i
1
I �
115.04
,I
�I
,I
4
114.4$ ,
Permit No.
Date Permitted ` 4)_
Builder Name/Owner Name��' Control #
County Parcel No.% L7aG Subliv:AMA '
AddressJLocation
Classification/Type of Use
Rate: Sq. Ft Unit:
Exempt Yes No How Determined
Impact Fee Amount Zone No. TAZ
SCHOOL IMPACT FEE
Account (056) Single -Family Detached House Amount $
(057) Mobile Home
(058) Other Residential
(123) Collection Fee
Exempt = Yes = No How Determined_
PARKS 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
BMW Checked By
PERFORMED UNTIL THE
S LISTED HAVE
BEEN PAID AND i 9 Ili
DATE RECEIVED BY
RECEIPT NO DATE BY