3122 W. Polk Ave.
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Anaheim Union High School District
501 Crescent Way, P.O. Box 3520, Anaheim, CA 92803-3520
(714) 999-2188
(714) 520-5741 FAX
CERTIFICATE of COMPLIANCE
PAYMENT of SCHOOL FACILITY FEES
NOTICE: The 90-day period in which you may protest the fee described herein will begin on the date this fee is
paid. However, if the fee was imposed by the City or County as a condition of approval for your project, and you
have received the requisite notice, the 90-day protest period began at the time your project was approved.
Receipt No:
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Owner Information:
Name:
Address:
Phone Number:
Applicant Information:
Name:
Phone Number: (
Property Information:
Address of Project:
Development Type:
Project Na me:
Type:
Elementa~",--'
High School District:
Anaheim Union High School District
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~~~
] Residential - New
~~~
[)O Residential - Room Addition [
] Commercial
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[
] Single Family
] Multi-Family Condos/Apartments - # of units:
Commercial:
Total Square Footage:
Multiplied by Current Rate: Elem. $
H.S. $
Equals Total Fee:
Fee Waiver:
Fees Waived:
Yes
Residential:
$
=$
-$
=$
[ ] Level 1 [ ] Level 2 . ACSD Only
Total Square Footage:
Multiplied by Current Rate:
Equals Total Fee:
Elem. $ ./.:2---=$qo .O't
H.S. $ J/v $10".0 r
$ 2~c/ -d?/~j~
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o
If yes, reason:
Acknow'edgement:
The above representations as to square footage are true. Developer/Applicant agrees that if it is later determined that such
representations are not true, Certificate shall automatically terminate and the appropriate City/County shall be notified.
Developer/Applicant Signature:
~
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Certification:
This certifies that the above named Developer/Applicant has paid school faclllty fees in compliance with Government Code
Sections 53080 and 65995.
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Date
Act~:
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Anaheim Union }-I.S. District
Jon High School District
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$
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Check No.
Check No.
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