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Name of Project/Permit #: BLD96-0249
Address: 422 SW 352nd Street
Tax Parcel(s)#: 066231-0560
Applicant [Person(s)
paying fee]: PETERSON HOMES, INC.
Address: P.O. BOX 23208; FEDERAL WAY, WA 98093-0208
Proj Planner/Fee Collector. FERNANDO FERNANDEZ/KARI CIMMER
3 r
Date Collected: vt
Total Amt Collected: $1707.00
Receipt Number:')
Name & Address of
Persons to receive refund: SEE APPLICANT INFORMATION ABOVE
FF.F.S COLLECTED
TYPE OF IMPACT
Type of Project/Location
Date to Refund Monies
Amount
Management Services
Quadrant
MITIGATED
Received
Account #
Account #
Traffic
Within 5 years of receipt
170-4300-000-345-85-000
8052
Streets
Within 5 years of receipt
170-4400-000-345-85-000
8053
Draina a/SWM
Within 5 years of receipt
170-3100-000-345-85-000
8051
parks
FW -- Within 5 years of
170-7100-000-345-85-000
8050
receipt
KC -- Within 3 years of
receipt
Schools
To be detennincd by the
Within 6 years of receipt
$1707.00
170-000-000-229-10-000
8054
School District
Other
Copy to: *Management Services (John Caulfield)
Traffic (Saeid Daniari)
Streets (Ken Miller)
Drainage (Jeff Pratt)
Parks (Jennifer Schroder)
Schools (Marie Mosley)
*Margaret Clark X
Copy of condition attached Yes _ No _
Entered into Permit Plan Yes X No
* Please always give a copy of the completed form to these people. Give a copy to the others only if they are directly
involved.
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