HomeMy WebLinkAboutPermit renewed, and pd fpua receipt i
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST
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PERMIT NUMBER: rDRESS:
I, ,am requesting that the above permit be renewed. I
understLU that I mush"schedule and pass all required inspections for the permit to be finaled. Further, I'
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/BLDR OR CONTRACTOR G A URE DATE
Print Name
STATE OF FLO DA <
COUNTY OF C� � ✓ //� 9
ACKNOWLEDGE BEFO ME THISA
DAY OF UJ 20 O
BY WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED AS IDENTIFICATION.
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STATE OF FLORIDA,County of
SIGNATURE OF NOTARY SEAL
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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
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Fort Pierce Utilities Authority
206 S, .6th Street
Fort 'Pierce, FL 34950
Receipt Number: PYMT00005744059
Receipt Date: 3/19/2018
Customer ID: 168970
Location ID: 10007517
Re Service Address:
On Behalf of: I
LELIA J BARNES
PO BOX 1025 1901 N 49 ST
FORT PIERCE FL 34954-1011 FORT PIERCE FL 34947
USA USA
Total Amount Received by Check $290.00
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