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BUTTE COUNTY SCHOOLS IMPACT FEE CERTIFICATION FORM ' l 0-000
(One form per Building)
School District 0 , j •P N Building Department No.
A.P. Number y w 3,.0-093 Jurisdiction: City County 4'
Property Owner , A o 4- A n f i t �4_ r_[ Q n/
Property Location/Address el c O r O
Subdivision
Residential Development 0
Q
No of Living
Mobile Home
Units
Installation
Commercial/Industrial 0
Q
New
Addition
Building Department
Lot No.
.............................................................. :........... ............................
Sq. Footage O
Addition/ 'Supplemental to (Group R)
Conversion Permit #
*(No foundation inspection)
i................................................................................................ _... i
Deed Restricted Sq. Footage
(Attach a signed copy of Deed Restriction and Notice of Limited Use Facility document),
Sq. Footage
(Including Exterior
Roofed Areas)
District Identification No. 040167
A(j4 School District certifies that
Date
(App icant)
(Street Address) (Phone Number)
(City)
has complied with the requirements of Resolution No.
representing square feet.
School District Representative
Paid by Check S ' �✓ Remarks:
(State) (Zip Code)
/0-15--190 by payment of $ �, �¢
JAB 2926 $
FULL MRIGATION =
I1z0
Date r -
C
Vilma
Notice: You may protest the Imposition of the fess Identified above by submiaing a wrltttn protest to the District, In compliance with
Government Code Section 66020(a), within 90 days from the daft hes are paid. Failure to submit a limey written protest wilfprohlbk
you from challenging the lmposlt o of to fess M any court action.
M, subsequent to the School Distrkt Rsprsstntativs signing this Butte County Schools Impact Fee Certlacatlon Form, the Sr pool District Is
notlfisd by the applicable Local PWWng Agency that this project Is being reviewed under to CalBomla Environmental Quaft Act (CEQA),
this project may be sub)ect to addkkmd school fess to fully m itigah Its Impact on the school district's schools.
White (applicant), Yellow (building department), Pink (school district) feefonn.xli (t0/03)dmm'
REVISIONS
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