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appendix 1 residential connection form and permit application

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Marina Coast Water<br />

11 Reservation Road<br />

Marina, CA 93933<br />

(831) 384-6131<br />

APPENDIX 9C<br />

COST OF CONSTRUCTION STATEMENT<br />

RECYCLED WATER SYSTEM<br />

Developer’s Name<br />

Tract No.<br />

Date Prepared<br />

Item Quantity Unit Price Total Cost<br />

$<br />

“SAMPLE FORM”<br />

ITEMIZE TOTAL CONSTRUCTED COSTS<br />

Subtotal:<br />

GRAND TOTAL INSTALLATION COST: $<br />

Prepared by<br />

My signature as witnessed here below attests that under penalty of perjury, the above statement is true <strong>and</strong> correct to the<br />

best of my knowledge.<br />

Date:<br />

Developer<br />

Official Title<br />

9C-1

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