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r <br /> STATE OF FLORIDA DEPARTMENT OFTRANSPORTAnON 960.@16 <br /> RECEIPT OF CONNECTION APPLICATION SYSTEMS PUNNNG <br /> AND FEE (OR WAIVER OF FEE) 003 <br /> hr <br /> IMPORTANT NOTE: Even though your application has been accepted, it may not be <br /> complete. We will contact you if more information is needed. <br /> w <br /> (1) APPLICATION NUMBER: ,? p j _ _ 1' 49 D <br /> APPLICANT: <br /> (2) Name/Address Iridian River County Board Of County Commissioners <br /> 1840 25th Ri- rPpt <br /> r Vero Beach , Florida 32460 <br /> (3) Project Name: CE 912. rnrri r`1 = Tmp y=e pni- s .Pha•s ® 4 <br /> y <br /> VEHICLES PER DAY FEE <br /> so (4) Fee <br /> 0 Category A 1 -20 $50,00 <br /> 0 Category 8 21 -600 $250.00 <br /> 0 Category C 601 -1200 $11000.00 <br /> 0 Category D 1 ,201 -4,000 $2,000.00 <br /> 0 Category E 4,001 -10,000 $3,000.00 <br /> 0 Category F 101001 -30,000 $41000.00 <br /> as 0 Category G 30,001 + $5,000.00 <br /> 0 Temporary $250.00 <br /> 4k Safety NO FEE <br /> 0 Government Entity NO FEE <br /> (5) Application Fee Collected $ (6) Fee Collected By <br /> 1M Payment: Certified Check Money Order Name <br /> Cashier's Check Check Number Signature (PRIIm <br /> Cash Date: Detict Unit <br /> (7) Receipt Given Back to Applicant Via <br /> 0 Hand Delivery 0 Mail 0 Courier Service 0 Other <br /> Applicant (or Agent) Signature (if available ) <br /> r This form bears your application number and serves as your receipt. <br /> (8) If fee is waived, give justification below or on separate sheet, <br /> FOR AGENCYUSE ONLY . ATTACH COPY OF CHECK ON THE NEXT PAGE <br /> so Make Checks payable to: State of Florida Department of Transportation <br /> it <br /> RECEIVED <br /> MAR ® 6 2007 <br /> PteRMTS <br />