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v. 2018.10.12 <br />City of South Bend <br />Department of Public Works <br />Utility Verification Form <br />pJf'il'it,v ^„,1 erificafio rP ,lee ,,.f 0 <br />.l.d <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 />Prop <br />Property Owner's Name: �� ,� C <br />Address/Lot #/Subdivision: Audubon Woods Section 2 <br />City, State, ZIP: South Bend, IN <br />0 Single -Family Residential ❑ Inside City <br />❑ Outside City & 1 /8 Contiguous <br />❑ Other m Outside City & Not 1 /8 Contiguous <br />The applicant is requesting the following connections: <br />0 Water <br />0 Sanitary Sewer <br />No. of ERUs*: 25 Peak Factor: _4 <br />* Equivalent Residential Unit (ERU) = 310 GPD <br />Residential Peak Factor = 4 <br />TIRE "too <br />IM City Connection Fee 36,450.00 <br />System Development Charge is billed by the City at the time the application for service is filed. <br />❑ Wastewater Survey for Nonresidential Establishments <br />(Note: May require industrial discharge permit and pre-treatment) <br />❑ Waiver of Remonstration to Annexation Agreement <br />❑ Annexation <br />❑ Requires System Improvements <br />Public Works Authorized Signature: Date:_qWl <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 />le <br />Property Owner or Representative Signature: r� Date: II O <br />Property Owner or Representative Phone: <br />** Form is not valid without Authorized Signature and Property Owner or Agent's Signature ** <br />UVF Fee Paid Date:- <br />