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BU¡LDING USAGE TYPË
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Mailing Address
!m¡il Address:
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Mailing Àddress
FmailAddre'ss:
Mailing Address:
Email Address;
PROJECT LOCATION AND
Job Address:
Assessor's Parcel
Building or Se¡uice
Dístãnce to Nparest Ëommun¡ty Sewer Systeñ:t/, h^il¿g
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Potable Water Source
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DocuSign Envelope lD: DFFA28Ds-EFB3-4C8D-94C8-8C957CF08FOE
CERTIFTCATIOT¡
I hereby acknowledge that I have reãd and understaîd lhe Notice and çerlificãtion above as
well as have provided the required information which is eor€ct ¿nd accurate to the best of
my knowledge.
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OFFICIAL USE ONIY oc)
Speciãl cond¡tions:,(
q5Totål FeËsr#-¡'74"'""ï"h?.ot'1#ffi9"
Buildinq Permitar?tr-ìlqllQ 0WTS Permit:.\ErlF-lqu3 lssue Dätê:"'ä2ç"bo
Gãrfield County Public Health Department:
5¡gnÊd Approvã¡Dâte
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01/17/2023
01/18/2023