9333 (SFD)u��cv
4
� q3 33
P.O. BOX 1504 APPLICATION ONLY
Building` / 7&105 CALLE ESTADO
Address tGSC V LA QUINTA, CALIFORNIA 92253
Owner
L C ey BUILDING: TYPE CONST. OCC. GRP.
Mailing //f
Address T
�3'doZ� E �7
A.P. Number
Y / �1
Zip
a -) G -,H C'onsg
Address
4/0-3yi She-)#-
ay o 6061-0 11
State Lic. City
& Classif. �3 _ o / a Lic. #
Arch., En �
Designer S 2DS
Address Tel.
0 -11 --,RM ! Z_ 3y�,
My Zip State
Lic. # —
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
O I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law.does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not,intended or offered for sale. If, hori•ever, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
C) I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or Improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any parson in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT. If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
.Mailing Address
City, State, Zip
FINANCE
Legal Descriptionc) V h i T
Project Description
ZONE: BY: -
Minimum Setback Distances: ,
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
Sq. Ft.No.
Size %cf, s�
No. Dw.
Stories Units
New `fi Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
..�
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
rastructure
_ O
O
TOTAL
REMARKS
ZONE: BY: -
Minimum Setback Distances: ,
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
DESERT SANDS UNIFIED SCHOOL DISTRICT
82-879 Highway 111
NOTICE: Indio, CA 92201
Document Cannot Be Duplicated (619) 347-8631
Date 1/16/91 1 Type of Permit I La Quinta
No. 110372 Permit #
Owner Name Landrace 1'0g #
No. street See Below
city La Quinta zip 92253
Study Area,
APN # Tract # j Lot # Square Footage 143M
Type of Development Single Family Residence No. of units
Comments Kd_n7_9; .T,,nrn7 (Area 11 n) 1;._RR1; Valaarn(Aran 1 11) nisi F%-Q_Qnn Axrn Ma"Af%�n
At the present time, the Desert Sands Unified School District does not collect fees on
garages/carports, covered patios/walkways, residential additions under 500 square feet,
detached accessory structures or replacement mobilehomes. It has been determined
the above-named owner is exempt from paying school fees at this time due to the
following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 1.58 X ®or $ 6,873.00 have been paid to D.S.U.S.D. for
the property listed above and that building permits and/or Certificates of Occupancy for
this square footage in this proposed project may now be issued.
Fees Paid By Hopewell Partners Ltd.
Name on the check
Telephone 7733125
By Richard M. Beck
`'t
Director, Facilities Planning & Development"; �;
J
r
Fee collected /exempted by Shelley D. Bennett ��
PaymLA-Recce
Signature a,�`f
1094
Collector: Attach a copy of County or City plan check application form to Disinct;cSgy*
Embossed Original- Building DeptJApplicant Copy.- Applicant/Receipt Copy - Accounting
09/06/-1990 15:17 FR011 FOSTER, f'E-PPER & SHEFELMHN TO 16197733097 P.02
Ord 162695 � �T
Escrow Not. 903276 -MA 0 NO. PCOR
Loan No.ig .
FIDELITY NATIONAl. TITLE. INS. CO. 'r .� �
WHEN RECORDED MAIL TO:
o.�
a.
LANDRACE CORPORATION (7om.Pors).. N.
c/o Foster Pepper & Shefelman .x w :d re `g
W Sec.uri ty Pacific Pi aza; • 15th Floor a �V
04 777. 108th Avenue. N . E . •' ,L �
CV' Bellevue, WA 98004
-SPACE ABOVE THIS LINE FOR RECORDEPM UAF
MAIL,TAX STATEMENTS T0: ,
DOCUIVMTARY TRANSFER TAX S ._3� .:. 25 _ ......__._.......
SAME AS ABOVE Coftuted on the consideration or value of property. conveyed; Oft
XX Computed on the consideration or value less liens or encumbrances
remaining at time of sale.
Slpnature of oeclerant or A"nl determining t►x — Finn N6me
..CORPORATION GRANT DEED
FOR .A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
T.P.M. HOLDINGS
a corporation organized under the laws of the State of Nevada does hereby
GRANTto LANDRACE CORPORATION, a Washington corporation ..
the real property in the City of La Qui n -td
County of Ri vers/.de State of California, described as
Property described on EXHIBIT "A'and EXHIBIT "B" attached hereto and by this reference
Dated lune 5, 1990
STATE OF CALIE&NIA ;
COUNTY OF (t •'r./' 1, �-!
OrL_jl1= 5, 1990 betorame,.
the undersigned, a Not895PuW1c In and toreeld State. Personalty apoear-
--
proved to me on the b0s of satisfactory
evide to be the persons wNo executed the v+ithln'lrotrumerd se
Ptesldent apo
_ . o.+ behatr cn l�v17
the corporation tt+erein name4 and admowledged to me that such cor-
poration .executed the within instrument pursuant to ft brlews or a
resolution of its board of directum . n
wrrNESS my 4ixf a)tnd flfflcia1
T.P.M. HOLDINGS
BY
THOMAS P. MOYER President
6Y *•�* Seel
OFFi0AfL SE
CYr:,:; L SR;��tvo
�.
Votary cNrlir, - Caiitomia ,
' -°-i my * E> COUNTY
OJca 8,1992
J9i06i1990 15:1e FROM FOSTER,PEPPER & SHEFELMAW TO
EXHIBIT "B"
16197733097 P.04
216235
,Ltt,-=4 in—Block""16.0-of--Santa- Carmelita_at Vale--La;r.Quinta,wUnit-No.
16 as perZmap recorded-in-Book--Page(.$)_,9.9.-,99of Maps; `in the
office-;- the-CountywRecorder of „Riverside County:. .----
PARCEL 2:
Lot 9 in Biock 58'of Santa Carmelita at Vale La Quinta, Unit No.
5 as per map recorded in Book 18, Page(s) 63 of Maps; in the
Office of the County Recorder of Riverside County.
PARCEL 3:
Lot 18 in Block 2 of Santa Carmelita at Vale La Quinta, Unit No.
1 as per map recorded in Book 18, Pages) 46, of Maps, in the
Office of the County Recorder of Riverside County.,
PARCEL 4:
Lots 10 and 11 in Black 93 of Santa Carmelite at Vale La Quinta,
Unit No. it ids per map recorded,in Book 18, Page(s) 75, of Maps,
in the Office.of, the County Recorder of Riverside County.
PARCEL 5: '
Lot 13 in Black 10.2 of Santa Carmelita at Vale La'Quinta,. Unit
No. 11 as per map recorded in Book 18, Pages). 75, of Maps,.in
the Office of'the County Recorder of Riverside County.
PARCEL 6:
Lott 23 'in Block 113, of Santa Carmelita at Vale La Quinta, Unit
No. 12 as per map recorded in Book 18, Page(s) 79 of Maps, in the
Office of the.County Recorder of Riverside County.
PARCEL 7:
Lot 11 in Block 64 of Santa Carmelita at Vale La Quinta, Unit No.
6 as per map recorded in Book 18', Page(s). 67 of Maps,* in* the • -
Office of the County Recorder of Riverside County.
PARCEL 8:
Lot 14 in Block 157 of. Santa Carmelita at Vale La Quinta, Unit
No. 16 as per map recorded in Book 18, Page(s) 99 of Maps, in the
Office of the County Recorder of Riverside County.
PARCEL 9:
,.,Lot 17 in Block 66 of,Santa Carmelita at Vale La Quinta,.Unit No.
6 as per map recorded in Book 18, Page(s) 67, of Maps, in the
Office of the County Recorder of Riverside County.
ULot 17—in�Blo-ck9--of--Santa- Carneli.ta`-at -Vale- La--Qu-inta, Unit
N.o 23 as per 'map` recorded in Book 20, Page'(s)-25; of Maps, in,
the f ice'�of-the -County Recorder of Rivers ide-County_._ _
CouNT "
,CrF�....��r•�...��.. '---�---fes,-•--- ��
on --,T
the ur►Aers�� otary,PubNc In and roreald $tete. personalyappear`
ed--�
God..
ja Proved to me on the Weis of satisfect"
evide)r+pe io be the peraom who executed the within instrument as
��--- - Prealdenta3d
on behalf ar Piy17 a��
the corporatbn therein named, and acknowledged tome that such cor-
poration executed the within instrument pursuant to Qg briOws or a
resolution of i" board of dinPctcxa'
WFFNESS m 4d and offl -w aea0 .�
By
THOMAS P. MOYER President
6y
OFFICIAL SEAL
Crr1;:; L. OR; No
%Ota'Y ' LN?jjk; - Caiifoftlia
ORANGE corm
rya, E�irfa Fc�. 28.1992
09/06/1990 15:19 FROM rOSTER,PEPPER & SHEFELMAN TO 16197733097 P.05
216235
ARCEL 1l:
Lot 19 in Block 84 of Santa Carmelita at Vale La Quinta, Unit No
lo.:as per map recorded in Book 18; Pages) 70, of Maps, in the
,.6ffice of the County Recorder of Riverside "County.
PARCEL' 7 2
- _. - ...
Lot 4 �n Block -2.5'7 �ofp°Sa'ntaCarmel=twat=-V'ale-La2!Quinta,--IInit No.
l24 -as ;per,`atiap recorded'" ok;,19, Rag _(s)� 4Y4 "and '45; of Maps=, in
tYie.$pffi.ceof-the-courityRecorderotRverside_:County.
PARCEL 13:
Loo I4 in Block 117 of Sana Carmeli.ta at Vale�La Quinta, Unit
No.. 12 as per map .recorded in 'Book 18, Pages) 79. and 80, of
Maps, in the office of the County Recorder of Riverside County.
PARCEL
Lot 24 in 3_:zc:k .158 of Santa Cariaelita at Vale. La Quinta,` Unit
No . 1'6 as ;nai recorded in Book. 18, Page (s) 99, Of Maps,. in
the office -.r.,- County. Recorder of Riverside County.
Said land is situatedin the City of La Quintbt, County of.
Riverside, Sate of California..
' 1
t ,
-x.
.' '. of
OFFICE OF i
o AGRICULTURAL COMMISSIONERj.
AND
`' 1
P't 4� WEIGHTS & MEASURES
' r - CALVIN C. KAMINSKAS
JAMES O. WALLACE 4080 LEMON STREET -ROOM 19 Asshlanl Commissioner
Agrleunurol Commissioner RIVERSIDE, CALIFORNIA 92501 CLEMENT BENVENISTE
Director of Weights A Measures (714) 787-2561 Sealer
49613 Highway 86,Suite B12 „ `>
Coachella, Ca. 92236
(619) 342-8291 _
DATE . /� �� ��CASE NO. J S 2 12 S'rD !r
DEVELOPER'S NAME:. /
1 .. Ara c e C 1�.0 �'�,-•. �� �f
ADDRESS:.
22 zGo
TELEPHONE: { 6 0 ).. 773 - 3 / z S'
Dear: Developer::
After reviewing your landscaping plans, all plant,material listed is not in
violation of quarantine laws ,governing the Coachella Valley., If substitutions
do occur and they differ from plant material listed, this office must be notified
immdiately.
Thank you for protecting and preserving the Coachella Valley's pest -free environment.
c`
Agr' tural Commissioner's Office r
is
cc: Indio and Riverside Office '-
- H
ii
i
, ' � ' • � � • l icer>v . Y I
xt
CIO
7i. I n Igll �
of Ka (auin'ta
f I i ii
1W
I ��7 � ♦ �, • �, i I'
I ' -ut♦NU auk .afet thtztuu
' �. . t 1' n r•. �, y '. .* -
(' I This Certificate issued ,pursuant to the requirements of Section 306 of the-Uniform Buildings
tl �I
i Code certifying that of the Nbe-of issuance this structure was in compliance with the various.
ordinances I& the, City: regulating building construction or use. For -the following:- i
A _� - • �� II it
BUILDING ADDRESS 52-835''Avenida+Velasco
I ! I I Use Classification . S FD --' ' Bldq. Pormit No. 93
33
Group R3 Type Construction VN w • Flre Zone Use Zone SR
Owner of'Building Landrace Corporation Address 73625 Hwy 111 #G`
City
�
Palm Desert CA 92260 W '<
By; Mark Harold I II
i '�yjr�•=,. Gate: 7/30/91 i
w
Building Official- ---
P6T+IN A CONSPICUOUS PLACE -11 bu_
—_: _�� -� , • _,� � , �� _ ����� :=��L�J �i�i���clllli�ivi�=l�����_;(`i.a�=:��`� j ;('V
,....�•%1�•., =--s.-.yam: ._ ....,+-�-.....Z .. -.+-�r= r`.r :-..� -
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH AIDO"O1 PufaM No.
ENVIRONMENTAL SERVICES DIVISION
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to County speculations as Indicated on the attached check list
r ' ` Anon -refundable filing fee (see below) is required when the application Is submitted. Check must be made payable to the County of
Riverside. Approval of this application shall remain valid for a period not to exceed one year from date of approval.
00 lie_'wl
Q . VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG #
Z
O Agent, Contractor, Contact Person Phone Address & Firm
~U
-_
LU
Owner // E ' ' Phone Maili Addre
U) � dna<e air �3-92����•olracc �vv
State Zip Job Prg�' d �, Least, Description (PM, Tract, Lot)
tf : �? z 6v �n 17�7uS'0 .'' F 4)
Lot Size Water Ag—en-c"alf"Use of Permit P/P, CU, etc. c, Other t
%Oen c t/ �/ • �� Dwelling; MH Site Prep; etc.
�Jd f `ten✓g
12, 4• f/%
U
Z
0
b
UJ
U)
bignattare-of Appaicantf
INI IAL DATE
Holding Tank Agreements Completed
Date
No
Cer`tlflcation of Existing S.D. System Required
CATEGORY:
REV CODE
FEE
CATEGORY:
REV CODE
FEE
`
❑
SUBSURFACE DISPOSAL
1238
$ 57.00
❑ SITE EVALUATION UPON REQUEST
7349
$ 43.00
Co
❑
MULTIPLE PARCELS WITHIN SAME
LAND DIVISION
No
(SNOT PLAN)
(13\( SEW /SEPTIC VERIFICATION
7348
$
�)
OZ
"Other
a. 1 st 4 Parcels (Each)
1238
$ 57.00
ass than 1 year)
❑Yes m
7
❑ 5 ❑ 6
b. Each Parcel after 4
7344
$ 24.00
/❑ PRELIMINARY ELECTIVE
7352
$ 23.00
W
❑
Rereview (2nd review same parcel)
7344
$ 24.00
EVALUATION (Attach DOH SAN 53)
No. of Systems
T eek
CD
❑
Site Evaluation in Conjunction with
Rasta
Greaee/Send
❑ HOLDING TANK
7351
$ 47.00
Critical Area
7346
$111.00
❑ ALTERNATIVE/EXPERIMENTAL
7345 - _
$222.00
❑
Site Evaluation Lot Less than
SYSTEM
}
10,000 Sq. Ft.
7347
$ 87.00
i
U
Z
0
b
UJ
U)
t
t7 This application s APPROV ENIED for the category chalked in SECTION B above, regarding the design of a subsurface disposal
ega 9 9 pose system as indicated
on the accompan plot plan, using'the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
-Z above -designed system. No construction is permitted in the required reserved 100% expansion area.
M (1) Septic tank and sewer lines must be 50' minimum from any wells
(2) Leach lines must be 100' minimum from any wells, including expansion area, »
LU ) (3) Seepage pits must be 150' minimum from any wells, including expansion area
Signature of Health Official
RECEIPT NO. �f Issued By Date
DISTRICT: ❑ Riverside, . It! dao- ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe -
{
DOH -SAN -122 (Rev. 3/90) DISTRIBUTION: WHRE Office fib YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
Vii; -.. __ �'.--- ... r -•-- -- --... _. o.. ._ .. .�S.a.:. .. ., ... - .. .... . .. ... .' .. -._._ - ,. -.
t
\
INI IAL DATE
Holding Tank Agreements Completed
❑ Yes -
No
Cer`tlflcation of Existing S.D. System Required
❑ Yes l7
No
Install
WQCB Clearance required. (Attach Form
❑ Yes
No
`
DOH SAN 007, Santa Ana Region Only)
ft rock/ . _ sq. fl
Per running t
m,
/
Sails Percolation Report Required.
❑ Yes r
No
`
,Specal Feasibility Boring Report Required.
❑ Yes
No
r Detailed Contour Ptot Plans Required (1 to 5 R interval)
❑ Yes
No
r-
Leachlines/bed special design for slope:
Applicable
"Other
❑ Yes r
No
(TD) Seepage Pit Total Depth
~ Staff Specialist Lot Inspection Required 6
❑Yes m
No
❑ 5 ❑ 6
!
Lot Inspection Date
/' /
Soils boring y T� (7�
Project
ik
Date
Soils Map Page Sol Type
Approved by
Dam
REMARKS: ('ORA
No. of Systems
T eek
.�
(1I Septic Tank
Rasta
Greaee/Send
❑ Holdl ❑Existing
Bedrooms lllin Units
Grease Inlcp
❑ New ❑ Reptecenwnt
t
t7 This application s APPROV ENIED for the category chalked in SECTION B above, regarding the design of a subsurface disposal
ega 9 9 pose system as indicated
on the accompan plot plan, using'the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
-Z above -designed system. No construction is permitted in the required reserved 100% expansion area.
M (1) Septic tank and sewer lines must be 50' minimum from any wells
(2) Leach lines must be 100' minimum from any wells, including expansion area, »
LU ) (3) Seepage pits must be 150' minimum from any wells, including expansion area
Signature of Health Official
RECEIPT NO. �f Issued By Date
DISTRICT: ❑ Riverside, . It! dao- ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe -
{
DOH -SAN -122 (Rev. 3/90) DISTRIBUTION: WHRE Office fib YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
Vii; -.. __ �'.--- ... r -•-- -- --... _. o.. ._ .. .�S.a.:. .. ., ... - .. .... . .. ... .' .. -._._ - ,. -.
t
\
Gel
Gd
(2) Leech Lire Sq. Ft
Sidewall at oe
Install
Line(s)'
R long ft wide with
Leach Bed eq it
Bottom trench area
ft rock/ . _ sq. fl
Per running t
m,
inchm rock
below drairlines or
` of bottom area
NA
r-
Leachlines/bed special design for slope:
Applicable
(3) Pit Diameter
No. Pits
.6Be
Inlet (BI)
(TD) Seepage Pit Total Depth
Other:
iJI9�c-Allowable- �pepth
N/A Overbu
❑ 5 ❑ 6
No. 2 System
REMARKS: ('ORA
C_• I/ GU,io—
Si., ¢,,'114
.�
t
t7 This application s APPROV ENIED for the category chalked in SECTION B above, regarding the design of a subsurface disposal
ega 9 9 pose system as indicated
on the accompan plot plan, using'the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
-Z above -designed system. No construction is permitted in the required reserved 100% expansion area.
M (1) Septic tank and sewer lines must be 50' minimum from any wells
(2) Leach lines must be 100' minimum from any wells, including expansion area, »
LU ) (3) Seepage pits must be 150' minimum from any wells, including expansion area
Signature of Health Official
RECEIPT NO. �f Issued By Date
DISTRICT: ❑ Riverside, . It! dao- ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe -
{
DOH -SAN -122 (Rev. 3/90) DISTRIBUTION: WHRE Office fib YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
Vii; -.. __ �'.--- ... r -•-- -- --... _. o.. ._ .. .�S.a.:. .. ., ... - .. .... . .. ... .' .. -._._ - ,. -.
t
B
�
a
'F
�
r
i e
fI COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL V
deceived From:
Address:
Account -7;93? �OC�3,6�aato(
S340e�o�454LVZS_ —� 3s-1/� G.A'. Code
Service Address ��
leter(s)
(�ervice(s)
SO av
❑ Backflow(s)
❑ HouseLateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
1�.nitation Capacity Charge a��5/ ;
❑ W.S.B.F.C.
y ❑Temporary Construction Meter
❑ Turn on Charge
! ❑ Uncollected Account - Name
�' ❑ Inspection Fee - Tract -
t , Fee -
�, ❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
I ❑ Other
Remarks: r `
❑Copy to:
Cash =.
j Check )
Money
Order
"a? _ 32545'
$ y�S"D, 00
2 5S701DO
l
Cashier
CMD -439 (11 /89)