1517 S. Selpulveda Blvd.
~ Ananelm union Hlgn :SChOOl District
501 Crescent Way, P.O. Box 3520, Anaheim, CA 92803-3520
~ (714) 999-2188
"III (714) 520-5741 FAX
.. .,..,,-.--
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CERTIFICATE of COMPLIANCE
PAYMENT of SCHOOL FACILITY FEES
NOTICE: The gO-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 gO-day protest period began at the time your project was approved.
Receipt No;
~sr;c
Elementary Di"'ct:
tj (!/ 5
High Schoor District:
Anaheim Union High School District
Owner Information:
Name:
Address:
Phone Number:
!A~-f1f '~r~~2~;~
)
Applicant Information:
Name:
Phone Number: {
Residential - Room Addition
Property Information:
Address of Project:
Development Type:
Project Name:
Type:
';(d
1 Residential ~ New [
YSo ~Iz.*~_
1 Single Family
Multi-Family Condos/Apartments - # of units:
Commercial:
~19.3
$ 115 = $ )/</l: /'1
$ .IX' = $'if!6' 7 (
. J(A - $('mf{
Residential:
[ ] Level 1 [ ] level 2 - ACSD Only
Total Square Footage:
Multiplied by Current Rate: Elem. $
H.S. $
[ 1
Level 3- AC50 Only
Total Square Footage:
Multiplied by Current Rate: Elem.
H.5.
Equals Total Fee:
$
=$
=$
-$
Equals Total Fee:
$
Fee Waiver:
Fees Waived:
Yes
Vl No
If yes, reason:
Acknowledgement:
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:
Certification:
This certifies that the above named Developer/Applicant has paid school facility fees in compliance with Government Code
Sections 53080 and 65995.
q:/2~&- S~J~
II
Date Union High School District
Actua~Cg7j
Anaheim Union H.S. District
$
$
?7F. '7cj
"if1l! . 7</
Check No.
Check No.
3.NY:
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DistributIon: Citv/Countv. DeveloDer - ACCDuntlno - Flpmpnt;\rV r'ti<:~ri'-+
tt>.. Cl-cg: ~
N? 171144
CITY OF ANAHEIM
FINANCE DEPARTMENT
COLLECTIONS OFFICIAL RECEIPT/DEPOSIT
RECEIVED FROM:
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151'1 :5 .sq;n"\IJ{'d(~ 6\0l\,
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FUNC
10
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4
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Deposit Breakdown:
CHECK (5):
QTY _ AMOUNT:
CURRENCY:
100'sx_ =
50'sx_=
20'sx_=
10'sx_=
5'5 X _ =
1'sx_=
Coin Total:
Currency Total:
...,~......,~...............,....,....,...........
)C.......ds.................TA..........b........C11.'~.)O. HLy)
... ........ .......... ..
OBJ
4
$ AMOUNT
'TOTAL:$~()1 q-),Q .Ob
""Please Do Not Write Below This Line""
Distribution: White - Acctg Yellow - Customer Pink - Reconcile Copy Goldenrod - Originating Dept.
Area Used for Cashier Validation
COL-18 Rev. 6105