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School District .
A.P. Number
Property Owner
BUTTE COUNTY SCHOOLS IMPACT FEE CERTIFICATION FORM .
` (One form per Building)
Building Department No.
Property Location/C
�g(% Jurisdiction: l City County
r
Subdivision Lot No.
Residential Dev=lopment Sq. Footage l u co
No of Living Mobile Home Addition (Group R)
Units Installation
Commercial/Incustrial
New Addition
Building Depar-ment Repre ri tive
(Floor Plain-relwed by School District Personnel)
District Identification No.
School District certifies that
(Street Address)
k.
(City)
has complied with the requirements of Resolution No.
representing O 6 �4 square feet.
I I L,'L� (/v-- - &.-
School District Representative
Paid by Check # (
Sq. Footage
(HKAUU11,1Y CALCFIVI
Roofed Areas)
Date
I �A_0�
(Applicant)
(Phone Numbed'
(State) (Zip Code)
by payment of $
B 2926 $
ULL MITIGATION $
Date
Remarks:
Notice: You may protest the imposition of the fees identified above by submitting a written protest to the District, in compliance with
Government Code Section 660201a), within 90 days from the date fees are paid. Failure to submit a timely. written protest will prohibit
you from challenging the imposition -of the'fees in any court action.
If, subsequent to the School Dis trict, Representative signing this Butte County Schools Impact Fee Certification Form, the School District is
notified by the applicable Local Planning Agency that this project is being reviewed under the California Environmental Quality Act (CEQA),
this project may be subject to additional school fees to fully mitigate its impact on the school district's schools.
White (applicant), Yellow (building department), Pink (school district) feeform.As (2/97)dmm