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<br />
<br />PASCO COUNTY, FLORIDA
<br />
<br />") J ' Iv)
<br />Builder Name/Owner Name /)/ ~ " tU,
<br />
<br />..L I ::;:' /1 "") ,fre-9--,-
<br />,17 ) ,_
<br />Permit No. '---'--' .~__,_ 7'- tAu
<br />, Date permlttedil:/~~~-!:); _~_
<br />p1V I,,{J ~) / ~^..J "',.. ,...' f Ii
<br />' (,/ f, L Control # '
<br />
<br />---------.---
<br />
<br />County Pattel No, (~z.,_,,;;J(' '/f :-!.,_~Z6(:~_,(i/'bl-fl-,_C)(~ ~lbDiv: _____________
<br />Address/Location ..')J/!_i,:I(!':':..~_~!"t~'!_.'-~'__L()t<J 1--? (]~/ / I~.., ! l' / ;:j.q ,~;~_~ ':;~,__
<br />
<br />Classification/Type of Use _'_,,_____
<br />
<br />EX8rnpt
<br />
<br />'-----'-'---,-------, .._-,-- {)
<br />
<br />Sq Ft Unit: _ ____ (J l(J -' ~ 1)/
<br />-. -"- - 'p l)
<br />How Determined ~~ ,\\ , I )J
<br />--------- -"--, - .-/\~-~\\)
<br />Impact Fee Amount ~____-==-_ Zone No. _.___ ~ --:- _~ I
<br />
<br />Rate:
<br />
<br />TR,ANSPORTATION IMPACT FEE
<br />
<br />[] Yes 0 No
<br />
<br />s6TiOoL IMPACT FEE
<br />Account (056) Single-Family Detached House
<br />(05"1) Mobile Home
<br />(058) Other Residential
<br />1123) Collection Fee
<br />Exernpt LJ Yes [J No How Determined
<br />
<br />Amount
<br />
<br />$
<br />
<br />--_._--..__._----_.~--_.._--
<br />
<br />-_._----_.__..~.._.------.
<br />
<br />---..-------.--.---.-
<br />
<br />PARks AND'RECREATION FEE
<br />Land Account Land Credit Land Total
<br />
<br />------~._---_._--- ---,---
<br />
<br />Recreation Account
<br />
<br />--~--------
<br />
<br />Recreation Credit
<br />
<br />Recreation Total
<br />
<br />2011e
<br />
<br />Exernpt [j Yes [I No
<br />
<br />TOTAL AMOUNT ,~..___,___.._,,_,____
<br />
<br />How Determined
<br />
<br />--- -'-~__._n_ - R.... ___
<br />LIBRARY FEE
<br />Land Account Land Credit
<br />
<br />_._-------_._---~_._----------_._----
<br />
<br />-------
<br />
<br />Land Total
<br />
<br />-..--.--.-..----------
<br />
<br />Facility Account _____,_,____ Facility Credit __
<br />
<br />._-_._---~---~_...._.-
<br />
<br />Facility Total
<br />
<br />Exempt IJ Yes [J No
<br />
<br />How Determined
<br />
<br />Total Amount
<br />
<br />~ESOURCE FEE '\ ~, c:;;,...,
<br />IOTALAMOlJNT .._~" 1":~:.:.-C~w.
<br />
<br />ERU
<br />
<br />---+.._-----------
<br />
<br />-...----.----------
<br />
<br />--- ~"-
<br />
<br />--
<br />
<br />Prepared By _______'__,____
<br />
<br />Checked By
<br />
<br />---------.--
<br />
<br />NO CERTIFIOATE OF OOCUPANCY WILL BE ISSUED OR FINAL INSPECTION
<br />PERFORMED UNTIL THE TOTAL AMOUNTS LISTED HAVE
<br />BEEN PAID AND
<br />RECEIPTED FOR BY A CENTRAL PERMITTING OFFICE OF PASCO COUNTY
<br />
<br />Aclmowledgement below does not Imply acceptance of concurrence, but simply receipt of a copy of this form, placing
<br />the building permit owner on notice of this assessment and the conditions of payment for same.
<br />
<br />-OATE-----'------------,- , RECEIVED BY..----~---
<br />RE(_-~EIP1' NO, '~"')' c-..?....-.::-;.;.?j." ~") / I'k.."\..~~. .t()(::j-,, <1" /,)(" (...",.,.....').. ,';
<br />, , ,I' .f DA T Ii. I' .7f I BY "1.:",,.,
<br />-"....",--------- - ---- ----- .----...L..-,_.._____
<br />
<br />
<br />
<br />( 9!(:~..'.' (~')
<br />6,,_0 /,'
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