Lee County Utilities

Developer Contributed Asset Project

Contractor’s Certification of Contributory Assets

Project Name:
Strap Number: / ,and,and
Location:
Owner’s Name: (as shown on Deed)
Owner’s Address:
Owner’s Address: / , -
Owner’s Telephone #: / ()

Type Utility System: Sanitary Sewer

(Please provide separate ‘Certifications’ for potable water, sanitary sewer, lift stations and reclaimed water facilities.)

Description and Cost of Material, Labor, and Services

Please list each element of the system from the drop-down list provided.

Unit cost MUSTinclude actual cost of CONSTRUCTEDfacilities in their entirety.

ITEM
/ SIZE /
QUANTITY
/ UNIT / UNIT COST / TOTAL
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE SDR-11HDPE SDR-11 CASINGHDPE SDR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
PVC C-900 DR-14PVC C-900 DR-18PVC C-905 DR-14PVC C-905 DR-18SDR-26HDPE DR-11HDPE DR-11 CASINGHDPE DR-17 CASINGSTEEL CASINGMANHOLETAPPING SLEEVE W/VALVEPLUG VALVESINGLE SEWER SERVICE/COMPLETEDOUBLE SEWER SERVICE/COMPLETETRAFFIC BEARING CLEAN-OUT (ADDITIONAL)PRESSURE CLEAN-OUT (FORCE MAIN)ARVFORCE MAINGRAVITY MAIN(REMOVED)(RELOCATED)(GROUTED IN PLACE) / 5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'x5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6'5/8"1"1.5"2"3"4"6"8"10"12"14"16"18"20"24"30"36"4'6' / LFEALS
TOTAL

(If more space is required, use additional forms(s).

I do hereby certify that the quantities of material and services described above are a true and accurate representation of the asinstalled cost of the system being contributed to Lee County and corresponds with the record drawings.

CERTIFYING:
X
(Signature of Certifying Agent)
(Name & Title of Certifying Agent)
(Name of Firm or Corporation)
(Address of Firm or Corporation)
, -

STATE OF )

) SS:

COUNTY OF )

The foregoing instrument was signed and acknowledged before me this day of , 20 by - , and who take an oath.

Notary Public Signature

Printed Name of Notary Public

Notary Commission Number (NOTARY SEAL)

Contractor’s Certification of Contributory Assets – Form (Revised - March 2012)

S:\ENGINEERING\DEVELOPMENT\Information and Forms\INFORMATION FORMS TO E-MAIL\00 - Developer Project Forms\07b - Certification of Contributory Assets (Sanitary Sewer) - form.doc