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, <br /> " ' �� `i P'A�C� ��llNT'Y, FL.OR�D►A <br /> . .. . ��m,~c c��. j9z�5 <br /> - Dats Parmifted I-76� <br /> ' Builder Name/Owner Name c��f��C� Controt# <br /> � County Parcel No. �S-�Z�''���Q-�iLt�-��� SubDiv: �.1li�x�� <br /> f; Address/Locatlon �Z�"� r`'' � <br /> >} E • <br /> Classi8catloM'ype o#Use c'3� �Z- <br /> t:�t, . <br /> ;=.. <br /> �:t= 7RANSFORTAj10N IMPACT PEE Rate: Sq.Ft Unit: �c�"� <br /> i;?, <br /> P:.` <br /> �:' Exempt �Yes [} Na Hortu determined <br /> `� � lmpact Fee Amount $. ��c3z� Zone Na. TAZ: <br /> ���. <br /> ?h� SGli00L{MPAGT FEE b <br /> '" Account {056) Singls-Family Detached kiouse Amaunt $ �t3 7(� �� <br /> �r�' (457} Mobite Norrte <br /> �o�a� Uther Res4denttaf <br /> � 123) CaHecttan Fee <br /> Exempt []Yes [�No How Determined <br /> � PARKS AND RECREATlAN FEE <br /> Land Account l.and Credit Land Total <br /> Recreation Account Recreation Credlt �Recreatian Tatal <br /> Zone Tt�TAt.AMdUNT $ �(��/���i <br /> � � Exempt []Yes � Na Haw Determined <br /> LIBRARY EEE <br /> - Land Account �and Credit �and Tota) <br /> - Faci{(ty Accaunt Facility Ccedit Facility Totai <br /> ° Exemp# ❑Yes ❑ M1la How Determined Tatal Amount ���^ <br /> � <br /> RESQURGE FEE ERl! ` <br /> TQTAL AMOUNT � <br /> Prepared Sy Checked By <br /> ' NO CERTIFICATE OF OCCUPANCY WILL BE ISSUED OR FlNAL INSPEC7lON <br /> tt PERF(�RMED UNTtL THE TOTAL AMOUNTS l.ISTED HAVE <br /> BEEN PAID AND <br /> RECEIPTED FOR BY A CEhlT'EtAI.PERMIT'Clf+lG OFFfCE Q�PASGO COUNTY <br /> �,. <br /> �`�' Acknowtedgement balow doss not Impiy acceptance of concurrence,but simpiy receipt of a copy af this form,ptacing <br /> the bullding permit owner on notics oE thls assessnnent and thq condtttons af payment for sama. <br /> DATE RECEIVED BY <br /> RECElPT NO. DATE BY <br /> � <br />