1853 ATLANTIC BEACH DR - PERMIT -0,J-\R:,---
)
'2"i. '' -, CITY OF ATLANTIC BEACH
l 800 SEMINOLE ROAD
;--:_,V- - '' ..._. 5-.)
ATLANTIC BEACH, FL 32233
__,y
,_____j
INSPECTION PHONE LINE 247-5814
SINGLE FAMILY DWELLING NEW
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 16-SFR-76
Job Type: SINGLE FAMILY RESIDENCE
Description: NEW HOME DRIVEWAY
Estimated Value: $375,964.00
Issue Date: 2/17/2016
Expiration Date: 8/15/2016
PROPERTY ADDRESS:
Address: 1853 ATLANTIC BEACH DR
RE Number: None /0
i \ —
GENERAL CONTRACTOR INFORMATION:
Name: TOLL BROS.,INC
Address: 250 GIBRALTAR RD STEVEN R MERTEN
Phone: - -
PERMIT INFORMATION: UTILITY DEPT.:
Ensure all meter boxes, sewer cleanouts and valve covers are set to grade and visible.
A sewer cleanout must be installed at the property line. Cleanout must be covered with an RT1
concrete box with metal lid. Cleanout to be set to grade and visible.
FEES:
ENG REV RESIDENTIAL BLD $100.00
PLAN CHECK FEES $653.95
UTIL REV RESIDENTIAL BLDG $50.00 tg. '�� •ti
BUILDING PERMIT FEE $1,307.89
STATE DCA SURCHARGE $19.62
STATE DBPR SURCHARGE $19.62
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
s .
iSS1
CITY OF ATLANTIC BEACH
p ' 800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
SEWER SDC-SYSTEM DEV CHG $4,050.00
WATER CONNECT/TAP & METER $370.00
WATER CROSS CONNECTION $50.00
WATER SDC-SYSTEM DEV CHG $1,140.00
Total Payments: $7,761.08
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH OFFICE COPY
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 247-5845
Job Address: 1853 Atlantic Beach Drive; Atlantic Beach, FL 32233 Permit Number: %6 - 5'F'R - 7 L
Legal Description Lot 50 Atlantic Beach Country Club Unit 2 67-132-08-2S-29E.204 Parcel
Floor Area of Sq.Ft. Sq.Ft
Valuation of Work$ 375,964 Proposed Work heated/cooled 3,278 non-heated/cooled 904
Class of Work(circle one): 00 Addition Alteration Repair Move Demolition pool/spa window/door
Use of existing/proposed structures) (circle one): Commercial Residential
If an existing structure,is a fire sprinkler system installed? (Circle one): oCN/A
Florida Product Approval# See attached
For multiple products use product approval form
Describe in detail the type of work to be performed: New Residential Construction
Property Owner Information:
Name: TOLL FL VI LIMITED PARTNERSHIP Address: 160 Cape May Avenue
City Ponte Vedra State FL Zip 32081 Phone 904 217-0739
E-Mail or Fax# (Optional)arogers@tollbrothers.com
Contractor Information: CONTRACTOR EMAIL ADDRESS: arogers(a),tollbrothers.com
Company Name: Toll Bros., Inc. Qualifying Agent: Steven R. Merten
Address: 160 Cape May Avenue City Ponte Vedra State FL Zip 32081
Office Phone 904 217-0739 Job Site/Contact Number 904 386-6472 Fax#
State Certification/Registration#CGC 1510225
Architect Name&Phone#
Engineer's Name&Phone#
Fee Simple Title Holder Name and
Address
Bonding Company Name and
Address
Mortgage Lender Name and Address
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the
issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. This permit becomes
null and void if work is not commenced within six(6)months, or if construction or work is suspended or abandoned for a period of sim
x(6)months at anytime
after work is commenced. I understand that separate permits must be secured for Electrical Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers,
Heaters, Tanks and Air Conditioners,etc.
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
COMMENCEMENT.
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing
this type of work will be complied with whether specified herein or not. The grantingof a permit does not presume to give authority to violate or cancel the
provisions of any other federal,state, or local law regulating construction or the performance of construction.
1
Signature of Owner dl Signature of Contract
g
Print Name Steven R. erten,Division Sr.Vice President Print Name Steven R. Merten
Before me Before me
this 21 Day of , December ,2015 this ./ D. . of December _,2015
Al
Notary Public Not.ry On 'c
Revised 01.26.10
;:15;:t;`4 MELISSA LIEBER'JMAN nY;... —
' _�`' e, :. MELISSA LIEBERMAN
i.,; •1 PRY COMMISSION#FF055o05 Jrk .
,F,_ -'�; . ._; I i MY COMMISSION,tFF055o05
1 ` EXPIRES September 18.2017 A
'''.11.-0,r.00/. " EXPIRES September 18.2017
(407)39£3-0153 Florid�NotaryServic�;.cam
(407)30f3.0153 Floriclallotary3orvico.com
DO NOT WRITE BELOW - OFFICE USE ONLY
Applicable Codes: 2010 FLORIDA BUILDING CODE
Review Result (circle one :
Approved -) Disapproved Approved w/ Conditions
Review Initials/Date: /-c) /6 /711k
Development Size
Habitable Space 'i a1? ' F Non-Habitable 904/ 5.F
Impervious area
Miscellaneous Information
Occupancy Group
Type of Construction 1/ 6
Number of Stories 2
Zoning District L ov14 /a y C l b
Max. Occupancy Load
Fire Sprinklers Required
Flood Zone
Conditions/Comments:
•
:11F CITY OF ATLANTIC BEACH
41 + ‘ Building Department
800 Seminole Road
400)
J_ r
A : Atlantic Beach,Florida 32233
.
(904)247-5800 OFFICE COPY
PLAN REVIEW COMMENTS
Permit Application # /6 — S FR— 76
Property Address: /?.5-3 0/. 906--A . A
Applicant: to// 6ro S',
Project: 4/9 Lv itio Ii e-/ Or ive way
This permit application has been:
❑ Approved
❑ Reviewed and the following items need attention:
C/ en19rjy Ca/c. 3 Ssves' S ode 1-1,•1'1A Perle.e ff S1Pvi9--
w,4 A /7l c Crowa0 f /- al, A :r".
i
ity\r
Please re-submit your application when these items have been completed."�
Reviewed By: — Date: I c}-7 -g
OFFICE COPY
q 3 ' CITY OF ATLANTIC BEACH
J ' Ott 800 Seminole Road
°;st) , EINE V Atlantic Beach,Florida 32233
,.� ; I Telephone(904)247-5800
VI .
j — FAX FAX(904)247-5845
FEB - 8 2016
"!DJtl9AI. ► e . 4, SHEET
Date: 02141 I .'. Resubmitted:
Permit Number: IC -SFR•1(/ Atlantic 'Each /t �Uto
Original Plans Examiner: Project Name:
Project Address: 1853 ftiiavth e 1eeaC.h Wye., J
Contractor:ID 11 IhC• Contact Name: IN €XS
Contact.Phone : D+ZI1-&13 el Contact e-mail:ar C @1-0 lord •Com
Revision/Plan Check/Permit Fee(s)Due: $ H let
Description of Proposed Revision to Existing Permit:
NW) Maru,lat s CoWlpliglh1e.. Reports qS kegl t'estcd Fvovvi Mil e Jones .
Additional Increase in Building Value: $ NIA Additional S.F. Ni IA
Site Plan Revised: NO Public W/U Approval:
By signing below. I(print name) Ashietj Rct 'S affirm that the above revision
ro osed changes.
inclusive o t' p p
ail .i .
Signa'. • ofContracto /Agent(Contractor must sign if increase in valuation) Date
Office Use Only
Date: c3/!IcL'V Approved: Rejected: Notified by:
Pla eview Co rents:
rove OS S'visrna Hoa/,
Dena[tment review required Yes No ,�y�
uildin9 `_----__.� / —
oning
Tree Administrator PI Examiner
Public Works
Public Utilities 2.. ._ .1_/ ! 4
Public Safety
Fire Services Date CK.tedv20/ts ney.2
1
Permits Page 1 of 1
1-6-15-D)
Permits
Gindlesperger,Toni [tgin@coab.us]
Sent: Wednesday,January 27, 2016 3:28 PM
To: Ashley Rogers
Cc: Jones, Mike[mjones@coab.us] OFFICE COPY
Attachments: 1871 ATLANTIC BEACH DR- P-1.pdf(219 KB)
You have the same problem at 1853 Atlantic Beach Dr. We are receiving design information from Mc Gowan's
Heating and Air Conditioning prepared by Renie Brown that are not filled out correctly and not inputting the
manufacturer's data.
In other words the holdup is Florida Energy Efficiency Code and Manual "S" requirements. Everything has been
approved but that.
Toni Gindlesperger
Building Permit Technician
City of Atlantic Beach
904-247-5800 ext 5800 ext 5852
tgin@coab.us
I
I
I
https://tmail.tol lbrothersinc.com/owa/?ae=Item&t=IPM.Note&id=RgAAAADJZwPXE7Fy... 2/1/2016
ickrAnv/ ' !6 - Scf?- 7G
NOTICE OF COMMENCEMEINT OFFICE COPY
State of: FLORIDA Tax Folio No. 169505-1545
County of: DUVAL
To Whom It May Concern:
The undersigned hereby informs you that improvements will be made to certain real property,and in accordance with Section 713 of
the Florida Statutes,the following information is stated in this NOTICE OF COMMENCEMENT.
Legal Description of property being improved: Lot 50 Atlantic Beach Country Club Unit 2,67-132 08-2S-29E.204
Address of property being improved: 1853 Atlantic Beach Drive,ATLANTIC BEACH,FL 32233
General description of improvements: NEW HOME CONSTRUCTION
Owner:TOLL FL VI LIMITED PARTNERSHIP Address: 250 GIBRALTAR RD. HORSHAM,PA 19044
Owner's interest in site of the improvement: FEE SIMPLE
Fee Simple Titleholder(if other than owner): .
Name:
Contractor: TOLL BROS.,INC.
4\
Address: 160 CAPE MAY AVE.PONTE VEDRA,FL 32081
1 Telephone No: 904-217-3852 Fax No: 904-460-2683
Surety(if any)
Address: Amount of Bond$ `
Telephone No: Fax No:
Name and address of any person making a loan for the construction of the improvements
Name:
Address:
Phone No: Fax No:
Name of person within the State of Florida,other than himself,designated by owner upon whom notices or other documents may be
served: Name: STEVE MERTEN
Address: 160 CAPE MAY AVE.PONTE VEDRA,FL 32081
Telephone No: 904-217-3852 Fax No: 904-460-2683
In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section
713.06(2)(b),Florida Statues. (Fill in at Owner's option)
Name:
Address:
Telephone No: Fax No:
Expiration date of Notice of Commencement(the expiration date is one(1)year from the date of recording unless a different date is
specified): 06/30/17
THIS SPACE FOR RECORDER'S USE ONLY OWNER
Signed: Date: to``(•S—
Before me I day of (h(1 Tortein the County of Duval,State
Of Florida, ': personally appeared S"fi1/l�
Notary Public at Large,State 9f Florida,County of Duval. 410P
Doc#2015237735,OR BK 17337 Page 581, My commission expires;/' 'tail ( I_�
Number Pages:1 Personally Known: �/ or
Recorded 10/15/2015 at 01:58 PM, Produced Identification:
Ronnie Fussell CLERK CIRCUIT COURT DUVAL :. '"°`•Z'•:. MELISSA LIESERMAN
COUNTY MY COMMISSION#FF055605
RECORDING$10.00 `
''rP' EXPIRES September 18.2017
0071398.0153 FloridallotaryService.com
I
' `,/' RECETVEIOfTY OF ATLANTIC BEACH
1 ' � 800 Seminole Road
P jl t 1 0 JAN fit2016 Atlantic Beach,Florida 32233
�) Telephone(904)247-5800
•. _ ..„ . . --_____._. FAX(904)247-5845
REVISION REQUEST SHEET
Date: VI 19 511(4/ Received by: Resubmitted:
Permit Number: I 1p—SFR" 7(0
Original Plans Examiner: Project Name:illiaritiC,Beach (,tDUrTfr 02 u-!o
Project Address: I G3 1 ircli G Belch Dove,
Contractor: TO6I BYo t YS I fC. Contact Name: 1
Contact Phone : 90�-2fl O1 Contact e-mail: Qlr s(d��I�S.COM
Revision/Plan Check/Permit Fee(s) Due: $ 0.00
Description of Proposed Revision to Existing Permit: .
_ 0,u S i4 plan roc .Public VKIOrKS COle.l2e oh j-}eryt S.
Maximum aYivewo.A3 WI•- iYi W °19 -0 -wi 1S .'4 . u -mt
12-P..VI pian so
' Additional Increase in Building Value: $ D• 00 Additional S.F. //g
Site Plan Revised: Public W/U Approval:
• By signing below.I .rint name) 1ShL tg- s affirm that the above revision
is inclusive of ti e )ro;osed changes.
•i :di i -- - ' -- - of a�Jui
•i
Signaturce•Co� ractor/Ag I ( • ractor must sign if increase in valuation) Date
; office Use Only
EC ElJVE -IDate: / i (o Approved: Rejected: Ni u[ftr
JAN 2 5 2016
Li-i
Plan Review Comments:
[,fr—r L tT /'P �! fl--
ti_
Department review required Yes No ir_..-----
�,iBuilding 11v ` •--`✓, W_-------
Planning&Zoning
1 Tree Administrator Plans Examiner
I. ,,.
` • •tic Utilitie /A..V i t;
1 `
=To lc Sa ety
Fire Services Date rnlea S120113 Rev.2
�,5S=4'�'�l f��, CITY OF ATLANTIC BEACH
DEPARTMENT OF PUBLIC WORKS
J _ '�St1 1200 Sandpiper Lane
Atlantic Beach,FL 32233 4318
S) TELEPHONE:(904)247-5834
I)'"'air)
" FAX:(904)247-5843
www.coab.us
CONTRACTOR: DATE: 1-22-2016
Toll Brothers,Inc. PERMIT# 16-SFR-76
160 Cape May Ave. ADDRESS: 1853 Atlantic Beach Dr.
Ponte Vedra,FL 32081
Email: arogers@tollbrothers.com
PERMIT APPLICATION FOR NEW HOME DRIVEWAY
Your permit application has been denied by the Public Works Department for the reasons listed below. Please submit this
information at your earliest convenience in order that we may approve your application. If you have any questions,please
contact Scott Williams,Deputy Public Works Director at 904-247-5834 or email swilliams@coab.us.
PUBLIC WORKS CORRECTION ITEMS:
(Submit the following information to the Public Works Department)
** Maximum driveway width in City right-of-way is 20'. Submit revised plans.
PUBLIC WORKS CONDITIONS OF APPROVAL:
(The following comments will be printed on your permit as Conditions of Approval)
** Full erosion control measures must be installed and approved prior to beginning any earth disturbing
activities. Contact Public Works(247-5834)for Erosion and Sediment Control Inspection prior to start of
construction.
** All silt must remain on-site during construction.
** Roll off container company must be on City approved list and container cannot be placed on City
right-of-way.(Approved:Advanced Disposal, Realco, Republic Services,Shappel's and Waste Pro.)
** Full right-of-way restoration,including sod, is required.
** Any utility cuts in the road must be repaired using COJ Standard Detail Case X and must be overlaid
10'in each direction from the center of the cut. Repair must be shown on the plans
** Maximum driveway width in City right-of-way is 20'. 1 E OE 11V E
cc: Toni Gindlesperger,Bldg.Dept. JAN 2 5 2016
r
S+..tvi,.7,; City of Atlantic Beach _ APPLICATION NUMBER
JS S, Building Department 11''i' . 57-IVED1 (To be assigned by the Building Department.)
Y i ; 800 Seminole Road // _S'�� ��
s Atlantic Beach, Florida 32233-5445 I Iv. . �r /
i� Phone(904)247-5826 • Fax(904)2zi 5843' i 2016
-o;1t�:- E-mail: building-dept@coab.us j .Y: Date routed: 0 /Z//G
City web-site: http://www.coab.us i b-� ---•• -_
APPLICATION REVIEW AND TRACKING FORM
ier
Property Address: /On / 4i,-/iC him Department review required Yes No
Applicant: l p /1 Y'Q Planning &Zonin
Tree Administrator
Project: /17L W m 6 )riV1/iJiy I' • Works
(--"ublic Utilities
Public safety
Fire Services
Review fee $ Dept Signature Z
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: ❑Approved. ®Denied.
(Circle one.) Comments:
,lie 4WUUhd 40/ >ir
BUILDING
PLANNING &ZONING0
/ � �
Reviewed by: 6. c� Date: / AZ
Amerlimmosir
TREE ADMIN. Second Review: r%Approved as revised. `Denied.
PUBLIC WORKS Comments: ,l(���i�/�i
lee �� � '�'L,��(!/
PUBLIC UTILITIES •7l/ !D (t(
PUBLIC SAFETY Reviewed by: — Date: -2/2/l b
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
-i,A,�if City of Atlantic Beach APPLICATION NUMBER
ri~ , Building Department (To be assigned by the Building Department.)
r i,., isj 800 Seminole Road. /� _S'��- ��
5 s •• Atlantic Beach, Florda 32233-5445
.` Phone(904)247-5826 • Fax(904)247-5845
• �o;319- E-mail: building-dept@coab.us Date routed: /L//4V
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Ai-
Property Address: /I5 , 7ii1 lieu D• • .rtment review required Yes No
Applicant: 1 0 // d S Plannin• &Zonin•
Tree Administrator
Project: / 1 L IV Mitt 6 )t, rii,(�jQ . Works
C ublic Utilities
Public Safety
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept.of Transportation _
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: ,E6Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONING b Date: 2
Reviewedy /� !
f
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
SLAN-j,, City of Atlantic Beach APPLICATION NUMBER
�s T f�r, Building Department (To be assigned by the Building Department.)
A. .i 800 Seminole Road /� —��� /�
5,ir -r Atlantic Beach, Florida 32233-5445 / (Y
Phone(904)247-5826 • Fax(904)247-5845 l
�0;;1>% E-mail: building-dept@coab.us Date routed: / /2/1/tf'
City web-site: http://www.coab.us !!!
APPLICATION REVIEW AND TRACKING FORM
ier
Property Address: /I6 in4,,he lieu D rtment review required Ye No
Applicant: j / S Planning_&Zonin
Tree Administrator
Project: N ✓ /71-0/77L I /77 p/"/ viol Works
ublic Utilities
Public Safety
Fire Services
Review fee $ _ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
_St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLI TION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING //
PLANNING &ZONING Reviewed by: Date: 11 I l'
TREE ADMIN. Second Review: ['Approved as revised. ❑De ed.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ['Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
S>,a,if,JCity of Atlantic BeachD�. - APPLICATION NUMBER
js r i, Building Department iEC -tom EP-0 be assigned by the Building Department.)
800 Seminole Road /� / /�
4 Atlantic Beach, Florida 32233-5445 J 1 $ 2016 _ / �
Phone(904)247-5826 • Fax(904)247-5845 l (/
"Apista'' S�E-mail: building-dept@coab.us Date routed: � 12/I
City web-site: http://www.coab.us ///
APPLICATION REVIEW AND TRACKING FORM
ler
Property Address: /I5 IFfi 4iei4 D- . .rtment review required Yes No
.•.a.
Applicant: /0 /1 "eyQ S Plannin• &Zonin•
I- / Tree Administrator
Project: /17LN L Mm )t-/ 'i (Jn,V 4-us - Works
("'ublic Utilities
Public Safety
Fire Services
Review fee $ 5-0 Dept Signature Jr vi-\
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: Approved. ❑Denied.
(Circle one.) Comments:
BUILDING
PLANNING &ZONINGReviewed by: Date: / i`1 11
TREE ADMIN. Second Review: ❑Approved as revised. ❑Denied.
C WOR Comments:
r�
BLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
Revised 07/27/10
iCLTli
�. • ��
' OF ATLANTIC BEAC
0 ., .r -� PUBLIC IC UTILITIES
1200 Sandpiper Lane
�s31�� ATLANTIC BEACH,FL 32233
(904)270-2535 or(904) 247-5874
NEW WATER/SEWER TAP REQUEST
Date: /- / 2- /& Project Address: /85-3 i a-,9€4,.. D�
No. of Units: ( Commercial Residential V Multi-Family
Tap(s)&Meter(s) '3 ..New Water Meter Size(s) ��
New Irrigation Meter V Upgrade Existing Meter from to (size)
New Reclaimed Water Meter ✓ Size '4 New Connection to City Sewer
Name:
Applicant Address:
City: State: Zip
Phone Number: Cell Number:
Email Address Fax:
Signature:
(Applicant)
CITY STAFF USE ONLY
Application# /to -J f/e, -7(0
Water System Development Charge $ L/Q, c10
Sewer System Development Charge $ ,US-D.(JO
Water Meter Only $
Reclaimed Meter Only $S-1,13&-0666 f (lQ
Water Meter Tap $ (notes)
Sewer Tap $
Cross Connection $ 5-0 ,
Other $
TOTAL $,-5:10/0. 06
APPROVED: Kayle Moore,PE 7<<'`/\.
(Deputy PW Director or Authorized Signature) ALL TAP REQUEST MUST BE
APPROVED BY UTLITIES DEPARTMENT BEFORE FEES CAN REASSESSED
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