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, � <br /> . � '�, <br /> ; <br /> j k �: <br /> � : ' �i""l��� ������' I� l�����1`� <br /> r <br /> ;J.� . <br /> 4• <br /> " Permit Na. __�__/��D <br /> Date Permitted <br /> B ilder Name/0wner Name ��r� (.� ��C�� Controt# <br /> C�unty Parcei No. � 2�O�- �/-.jj 2-I�7�,-j,��j[;�?'f]�.Z4 SubDiv: �aj�`'1�1` �'" <br /> �,r� Ci��r}� <br /> A�dressiLocation ,''��] ��� �`YGtr t��`�' l?�e �,� � 7��� � <br /> � � <br /> Classification/Type of Use G�� ���-. <br /> TRAIVSPORTATIORI I(WPACT FEE Rate: Sq Ft Unit: �� <br /> Exem t Yes No How Determined <br /> p ❑ ❑ <br /> � Ir�ipact Fee Amount $ ..�� ��p• Zone No. TAZ: <br /> S HOOL IMPACT�EE <br /> A count (Q56} Single-Famify Detached House Amount $ � <br /> (057} Mabiie Home <br /> (058) Other Residentia! <br /> 123) Cailection Fee <br /> E empt [� Yes [] No How Determined <br /> P' RKS AND RECREATION FEE <br /> L nd Account l.and Credit l.and Tatai <br /> ecreation Account Recreatian Credit Recreation Totai <br /> Z ne TOTAl.RMOUNT $ 7�, �� <br /> E� empt [� Yes [� No How Determined <br /> L�BRARY FEE <br /> L nd AccounE Land Credit L.and Total <br /> F�acility Account Facifity Credit Facility Totai <br /> xempt ❑ Yes [� Na How Determined Total Amount �i� <br /> ESOURGE �EE / _ ERU <br /> QTAL AMOUNT �� �.�J� � ��'''� <br /> ' �(f l <br /> �repared By 'I� Checked By <br /> NQ CERTIPICATE t?� 4CCUPA,NCY!N{LL �E 15SUED OR F1P1AL INSPECTit3N <br /> PEFiFORMED UNTi�.THE TOTAL AMOUNTS LISTED HAl/E <br /> BE�1� PAIC! AId[� <br /> RECEIPTED Ft�R BY A CENTRA�. PE62MiTT1NC t'3FF'iCE�.t� PA5C0 COUNTY <br /> cknowledgement below does not imply acceptance of concur�ence,but simply receipt of a copy of this farm,placing <br /> the building permit owner on natice of this assessment and thQ canditions af payment for same. <br /> l� � I �. �. �.�����.C� <br /> �ATE RE EIVED BY <br /> RECEfPT NO. DATE �- �.7 BY ���.` ` ! <br />