Get Impact Fee Acknowledgement Form

SUPPORTING DOCUMENT DEFERRED IMPACT FEE ACKNOWLEDGEMENT Building permit number - I/We as owner s of the property for which the building permit identified above is issued acknowledge that this building permit is subject to the impact fees required by Kitsap County Code KCC Title 4 Chapter 4. 110. The amount of the deferred impact fee required for this building permit is. I/We acknowledge that pursuant to Kitsap County Code Chapter 4. 110 the above impact fee must be paid before the Certificate of Occupancy may be issued* I/We agree to pay the above stated fee in accordance with the Kitsap County Code before the structure pursuant to the building permit identified above is occupied* issued or if the building permit expires during construction Kitsap County Department of Community Development DCD will send written notification to the following address that the impact fee is or may be due. I/we understand however that the payment of the impact fee prior to occupancy is my/our responsibility with or without written notification Owner s Name Owner Mailing Address City State Zip Code Notice to Title against the property and initiate collection procedures to recover the impact fee and any collection fees to the extent allowed by law. Dated this day of 20. Owner Signature Owner Name Printed Kitsap County Department of Community Development 614 Division Street MS-36 Port Orchard WA 98366-4682 www. kitsapgov*com/dcd/ Revision Date 4/24/2012 Phone 360 337-5777 Fax 360 337-4925 Form Number 1204D Email Kitsap1 co. 110. The amount of the deferred impact fee required for this building permit is. I/We acknowledge that pursuant to Kitsap County Code Chapter 4. 110 the above impact fee must be paid before the Certificate of Occupancy may be issued* I/We agree to pay the above stated fee in accordance with the Kitsap County Code before the structure pursuant to the building permit identified above is occupied* issued or if the building permit expires during construction Kitsap County Department of Community Development DCD will send written notification to the following address that the impact fee is or may be due. 110 the above impact fee must be paid before the Certificate of Occupancy may be issued* I/We agree to pay the above stated fee in accordance with the Kitsap County Code before the structure pursuant to the building permit identified above is occupied* issued or if the building permit expires during construction Kitsap County Department of Community Development DCD will send written notification to the following address that the impact fee is or may be due. I/we understand however that the payment of the impact fee prior to occupancy is my/our responsibility with or without written notification Owner s Name Owner Mailing Address City State Zip Code Notice to Title against the property and initiate collection procedures to recover the impact fee and any collection fees to the extent allowed by law. I/we understand however that the payment of the impact fee prior to occupancy is my/our responsibility with or without written notification Owner s Name Owner Mailing Address City State Zip Code Notice to Title against the property and initiate collection procedures to recover the impact fee and any collection fees to the extent allowed by law. Dated this day of 20. Owner Signature Owner Name Printed Kitsap County Department of Community Development 614 Division Street MS-36 Port Orchard WA 98366-4682 www.