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� � = f'ASCA C{�UNTY, �LORID�► <br /> � " Permit iVo. ��� <br /> Date Permitted �� - � <br /> Buiider NametOwner Name / ��`���-�' Gontrol# <br /> ���+� �, !`,� Lf <br /> Coun Pares(No, -�-u-� r��-i� U�1 d SubDiv: tN��-T <br /> �► . ���" <br /> AddresslLocatian _;37t�s7 ��'T,c.t�'"t°,�C.('dS�. LU <br /> Classiflcat(onlType of tlse f�lttA'�^2. <br /> 7RANSPORTA7i�N IMPACT FEE . Rate: Sq.Ft Unit: _����� <br /> Exempt [�Yes [] No Houv Determined <br /> � tmpact Fee Amount � 3 t 6 3 a-- Zane Na. TAZ: <br /> SGHOOL IMPAGT FEE <br /> Accaunt (056) Single-Famlly Detached House Amount $ _�._���� <br /> (057) MobUe Home <br /> (458} Other Residential <br /> 123) Coitection Fee <br /> Exempt [t]Yes [�No How Determined <br /> PARKS ANQ RECREATION FEE <br /> Lend Account Land Credit Land Totai <br /> Recreation Accaunt Recreatian Credit �Recreation Tatal <br /> Zone TOTAL AMOUNT $ 7(�`f'-cS� <br /> Exempt []Yes [� No kiow Determined <br /> UBRARY FEE <br /> ; Land Rccount Land Credit Land Totai <br /> . <br /> i Facii'tty Account Facility Credit Faoilfty Tatai <br /> IExempt ❑Yss ❑ No Now Determined Total Amount � <br /> RESOURCE FEE ERU <br /> TOTAL AMOUNT � <br /> Prepared By Checked By <br /> � NQ CERTtFICATE OF OCCUPANCY WILL BE{SSUER OR PINAI iNSPECTION <br /> PERFORMED UNTlL THE TOTAL AMOUN7S I.ISTED HAVE <br /> BEEN PAlD AND � <br /> RECEIPTED F4R BY A CEN7RAL PERMITiiNG OFFtCE•OF PASCO COUNtY <br /> Acknowledgement be►ow does nat Imply acceptance of concurrencs,but slmp{y receipt of a capy of this form,placing <br /> the butlding permlt owner on notice of thfa assessmsnt and tha condltions of payment#or sams. <br /> QATE RECEIVED BY <br /> RECEIPT NO. DATE BY <br /> _.,.��.-----�--�°-°-- ' <br />