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STATE -OF ELOR IDA DEPARTMEN7'OF TRANSPOR'r.AnoN 850060116 <br />RECEIPT OF CONNECTION APPLICATION sYsrFeasPiAx <br />AND FEE (OR WAIVER OF FEE) <br />IMPORTANT NOTE: Even though your application has-been ac wgted, it may not be <br />complete: We will contact you if lraore. informatiotl is needed: <br />(1) APPL1cAnoN NUMBER: <br />APPLICANT: <br />{2) Name/Address <br />Iridian. Rivet County Public Works <br />1801 27th Street. <br />'hero Beach FL 32960 <br />(3) Pro)ecfMame: <br />Atlantic Blvd. Parking Facilities at 20th Street {SR60) & 43rd Avenue & 42nd <br />Avenue <br />VEHICLES PER DAY f5E <br />(4) Fee 0 <br />mon; A 1-20 $5000 <br />0 <br />Category B 21-600 $25000 <br />0 <br />Category C 601-1,200 11;000 00 <br />0 <br />Category D 1.;20I 4;0DO $2,OOQ 00 <br />d <br />Category E: 4;001-10 000 <br />0' <br />Category F 10 001.30,000 $4,00000 <br />0 <br />Category G 3D.001 + $51Q00 90 <br />0 <br />Temporary $25D O0. <br />..0 <br />Safety NO FEE <br />0 <br />Government Entity NO FEE <br />(5) Application Fee Collected $ <br />(6). Fee Collected By <br />P"enrt T <br />_ - .. _.._ . ..... . <br />Alanie - <br />Money Order 0,Nn <br />Check O Check Number <br />Sigriaturti <br />Cash O <br />late-, District Unit <br />(7) RecelptGiven Back.to-ApplicantVia <br />O Hand Delimy <br />O.Ma71 O Coitrier'Service. 0 Other <br />Applicant (cr.Agent) Signature (f avalAble) <br />This form beam your application number and serves as your receipt. <br />J8) if fee is waived, give justification below or �on sapamte sheet. <br />FOT{AGENCY USE ONLY - ATTACH COPY OF CHECK ON THE NEXT PAGE <br />Make Checks payable to' State of Florida Department of Transportation <br />Approved <br />2018-A-490-01 <br />Mesa Harden <br />5/8/2018 <br />