West Orange Compiled ZBA Application 5 15 24

STATE OF NEW JERSEY NON-RESIDENTIAL DEVELOPMENT FEE CERTIFICATION/ EXEMPTION SECTION A (To be completed by developer): Developer Name of Developer:_| Public Service Electric and Gas Company (PSE&G) Address: [4000 Hadley Road, South Plainfield, NJ Phone: |(848) 210-0195 | Fax: | | E-mail: | Robert.Pollock@pseg.com Property Location _ —_ _ County: | Essex __| Municipality: [West Orange | Block: [155 | Lot: [26.01 | Qual.: | Street Address: [325 Mount Pleasant Avenue Date(s) on which Developer received preliminary and/or final site plan approval: ] Construction Permit Application Number: L Date on which Developer first sought construction or demolition permit (section 37 of P.L. 2008 ¢.46): I Exempt From or Not Subject to Fee [Section Citation of P.L. 2008 c, 46(C. 40:55D-8.1 et seq.| Check one if appropriate UO | Non-profit Educational Purposes [35b] C1 | Transit Hub [35b.(4)] C | House of Worship [35b] Transit Village [35b.(6)] © | Parking lots and structures [35b.(1)] Transit Hub-Light Rail [35b.(5)] Oo Non-profit hospital relocation or improvement Public amenity (recreational, community, senior centers) im oO [35b.3)] [35b.(2)] (Attach Planning Board approval) | State, County, and local government buildings Commercial Farm or Use Group U Buildings and Structures _| Approval granted prior to July 1, 2013 [37a. (1,3-5) 8oOoo Non exempt status [Section citation] Check one if appropriate 1 | Prior payment or commitment for low and moderate income housing [37c] _| Amount paid: | $ (J [ Non-residential planned development, subject to a development or redevelopment agreement entitled to a 1% fee [37a.(2)] (| Full Fee Due (2.5%) IF AN EXEMPTION OR REDUCED PAYMENT AMOUNT IS CLAIMED, THE DEVELOPER SHOULD ATTACH SUBSTANTIATION FOR THA CLAIM. I, the undersigned, understand that this declaration and its contents may be disclosed or provided to the State of New Jersey and that any false statement contained herein may be punished by fine, imprisonment, or both. I further declare that I have examined this declaration and, to the best of inoagaee and belief, it is true, correct and complete. Signature of Developer: [ Name: |By: Robert Pollock, Public Service Electric andGas Company ro Title: | Director, Environmental Projects and Permitting [Dats [| S Jasou — = — SECTION B (To be completed by assessor): ‘ Estimated Final Assessed Value $ El $

c Service Electric andGas Company ro Title: | Director, Environmental Projects and Permitting [Dats [| S Jasou — = — SECTION B (To be completed by assessor): ‘ Estimated Final Assessed Value $ El $ FL Director’s Ratio % | B2 % | F2 Equalized Assessed Value $ B3 $ F3 Existing Equalized Assessed Value — | $ FA $ FA Ifnew construction, use $0.00/NA. _ Amount on Which Fee is Calculated | $ ES (E3-E4) $ FS (F3-F4) Non-residential Development Fee $ E6 (ES X 2.5%) $ F6 (FS x 2.5%) Signature of Assessor: | Date Name: | Exempt: im — === — =- ——— SECTION C (To be completed by municipality) Payment Amount: | $ | Amount should equal E6 or F6 Payment received by (name): _ | Signature: Name: Title: [Date:_| (N-RDF- rev. 10/24/13)