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v. 20118.10.12 <br />ti City of South Bend <br />Department of Public Works <br />Utility Verification Form, <br />Please submit <br />Utility Verification fee of $50 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 avoilobfe in c 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 Informgtign ag Be CompJ&ted By A1212liggnt): <br />Property Owner's Name: Postmark Bloomington LILC <br />Address/Lot #/Subdivision: <br />City, State, ZIP: <br />522 E. Napoleon Boulevard <br />South Bend, IN 46�617 <br />* Single -Family Residential EI Inside City <br />0 Outside City & 1/8 Contiguous <br />* Other 0 Outside City & Not 1/8 Contiguous <br />The applicant is, requesting the following connections: <br />IRI Water No. of ERUs*: I Peak Factor: 4 <br />121 Sanitary Sewer Equivalent Residential Unit (ERU) = 310 GPD <br />Residentiot Peak Factor = 4 <br />0 City Connection Fee $ 1,458.00 <br />Sysfem Development Charge is billed by the City at the time the application for service is tiled. <br />0 Wastewater Survey for Nonresidential Establishments <br />(Note: May require industrial discharge permit and pre-treatment) <br />11 Waiver of Remonsfra lion to Annexation Agreement <br />0 Annexation <br />11 Requires System Improvements <br />Public Works Authorized Signature: _Z-orZ4 PI)161U-a-� Date. 014/07/2020 <br />By executing this Utility Verification Form, you hereby acknowledge the statements contained herein are true and <br />accurate, if the City toter determines that you misrepresented any statement on this Utility Verification Form, you wale <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 eet the requirements set forth above. <br />Property Owner or Representative Signature. Date: 04/03/2020 <br />Property Owner or Representative Phone: <br />574-229-6659 <br />* e/ot;, 1>11-0 . CAa- <br />** Form is not valid withoa ut Authorized Signature and Property Owner or Agent's Signature ** <br />SDCs Paid Date: 04/07/2020 13 Checkil 13 Check # —2AO-a— <br />UVF Fee Paid Date: 04/07/2020 13 Credit <br />0 Cash 0 Cash <br />