HomeMy WebLinkAboutPermit renewal, , pd FPUA receipt I ,
ONCE 5D.-)- C)LCA X1.0
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMINUMBER: ADDRESS: ��� 00
am requesting that the above permit be renewed. I
understan tat ust schedule and pass all required inspections for the permit to be finaled. Further,'II
understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a
passing inspection during any six month period during the renewal period.
Justification
OWNER/BL R OR CONTRACTOR SIGNATURE IATE
Print Name
STATE OF FLO D
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 20
BY �� �Z'LC�e.Q� WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of
SIGNATURE OF NOTARY SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get%of open inspections)
Percentage:
Original permit fee: x%open = $ Renewal fee
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014
Fort Pierce Utilities Authority
206 S 6th Street
36-
Fort Pierce, FL 34950
Receipt Number: PYMT00005790167
Receipt Date: 4/24/2018
Customer ID: 168970
Location ID: 10007553
On Behalf of: Re Service Address:
LELIA J BARNES
PO BOX 1025 1808 50 ST
FORT PIERCE FL 34954-1011 FORT PIERCE FL 34947
USA USA
Total Amount Received by Check $290.00
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