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v. 2018,10.12 <br />K City of South Bend <br />y Department of public Works <br />Utility Verification Form <br />Please submit <br />Utility Verification fee of <br />to» <br />City of South Bend/Public Works <br />Permit Office <br />227 W. Jefferson Blvd <br />South Bend, IN 46601 <br />Pursuant to the City of South Bend Municipal Code § 6-4.1 and 17-79 through 17-87, the Permit Manager's <br />Office has verified available utilities and connection requirements. This form is for the express purposes of <br />notifying an applicant of whether City utilities are available in a particular location and what requirements are <br />necessary for connection. <br />IT DOES NOT GUARANTEE CONNECTION TO CITY UTILITIES or CONSTITUTE A TAP PERMIT. The applicant must <br />meet the requirements below prior to receiving tap permits to connect to City utilities: <br />Property Owner's Name: <br />Address/Lot #/Subdivision: <br />City, State, ZIP: <br />Star 001, LLC <br />3323 Prairie Avenue (S. R. 23) <br />South Bend, IN <br />❑ Single -Family Residential M Inside City <br />❑ Outside City & 1 /8 Contiguous <br />M Other ❑ Outside City & Not 1 /8 Contiguous <br />The applicant is requesting the following connections: <br />M Water No. of ERUs*: 7 Peak Factor: 4 <br />IJ Sanitary Sewer * Equivalent Residential Unit (ERU) = 310 GPD <br />Residential Peak Factor = 4 <br />Cry Requirements iL Be Completed by the COX of South Beno: <br />® City Connection Fee $ 10,206.00 <br />System Development Charge is billed by the City at the time the application for service is filed. <br />0 Wastewater Survey for Nonresidential Establishments <br />(Note: May require industrial discharge permit and pre-treatment) <br />13 Waiver of Remonstration to Annexation Agreement <br />• Annexation <br />❑ Requires System Improvements <br />Public Works Authorized Signatur Date: <br />By executing this Utility Verification Form, you hereby acknowledge the statements contained herein are true and <br />accurate. If the City later determines that you misrepresented any statement on this Utility Verification Form, you will <br />be charged the corrected City connection fee. You understand the requirements to connect to City utilities as set <br />forth under South Bend City Ordinance and agree to meet the requirements set forth above. <br />Property Owner or Representative Signature: Zmz_ 2=XIZ Date: _ glol-a <br />Property Owner or Representative Phone: 120 - 6-05 <br />*' Form Is not valid without Authorized Signature and Property Owner or Agent's Signature'* <br />Check�f Check # <br />Paid Date: UVF Fee Paid Date: Credit <br />SDCS a Au 0 Cash a Cash <br />