HomeMy WebLinkAboutUTILITYS PAPPERWORK-- f
SCANNED
BY
St. Lucie Countv
Temporary Water Service
City of Port St. Lucie Utility Systems Department 0GANNEL
BY
Phone: (772 ) 873-6400 Fax: (772) 871-7615 Email: Utileng@cityofpsi.com
1AClo1*rA1lA9e$- St. LUCjeC0j)n,
Temporary Water Meter Permit Application and Agreement for Service
Type of meter needed. HydrantAssembly FZ�"JumperAssembly
Phone #1 7 V - 7r) /) -Z 7 A 7—
Fax# I :77,�-�RQ-R:2,Qgy
Billing Address Street Address city State Zip
I Meter Size: / 5/8 x 3/4" ) ill 2" 3- (indicate meter size requested.) I
IMeter Size: . 4" 61. B.. 1 101, (indicate meter size requested.) I
Proposed Location: 6. M- �.` 1/5 14 1-/ i� / &t � 5L 1 1 1
Street Address Lot Block Section
Nearest Cross Street
*"*Attach an 8 112"x 11" map of the proposed location of fire hydrant orjumper assembly.****
Terms of Agreement: As a representative of 1--,.e A5ZL,"44 6r— the undersigned
acknowledges:
1. Responsible for leaving the construction meter assembly in the assigned location and for displaying the
permit tag.
2. Responsible for any and all damage to private property that may result from utilizing the backfiow assembly.
3. Responsible for any property damage, including, but not limited to, the PSLUSD meter and backilow, assembly and/
or PSLUSID water distribution system, due to negligent use of the backilow assembly, theft or vandalism.
4. In the event of loss, theft, or vandalism, the refundable deposit is forfeited.
5. Responsible to pay for all related metered water consumption.
Permit Time Extensions: The permittee is responsible for monitoring their permlfs expiration date. A permittee may request
time extensions in 180-day increments. A permit extension fee applies.
Meter Relocation: The permittee may request the relocation of a specific permitted temporary meter if it is to be relocated to
another location within the boundries of the development for which is originally proved service. A relocation fee applies.
New MeterEr Meter Relocation Time Extension F1
Applicant's Signature:
New Exp. Date
Date:
PSLUSD Engineering Use Only
Cross Connection Use Only
Customer Service Use Only
Project Name: C>k 01 . oz>CA6
Permit Date:
Amount Received:
V-Pl- —)V
Piroject Number.,
P.mnit N.mben
Receipt No.:
Approvedjk�= Date, 10
Permit Expiration I
Date;
cc; Cross Connection
Effective Date: 10/0112010
PSLUSD Doc No. 25
Receipt # 08415 Account #
CI City of Port St. Lucie
:I'D 9V Utility -Engineering Depart
Project Name:
Service Address: �8?,T SOO-�H OS
Billing Name:
Billing Address: (5_!�
Legal Description: Jz) rA f—)C::
Application Fee: Agreement Fee: F-I ertm
Received b y: 6
4
File #
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Date: Amount: KO__
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Felix Agsociates of Florida. Inc.
CITYOFPSLU CIT F PORT ST LUCIE UTILITIE
DECkILICTION
',BA V�NCE
6-08-15 060815 METER DEPOSIT/INSTALL
450.00
450.00
CHECKa.. 6-08'
CHECK
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450'
DATE:-,��,
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*tes of Florida.
immON
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�15.��060815 METER-' DEPOSIT/
�p� 450',
m,� 4 5'0',. 00,
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CHECK
6-08
CHECK
�463 61
f6TA6;' 0 00"-
459�bo
'DATE,
TAINFORYOUR'RECORDS
'PLEASE DETACH ANDRE
2
Felix Associates of Florida, Inc.
8526 SWKansas Avenue
Stuart, FL 34997
Bank of America -
DATE CHECK NO.
June �, 2015 29036
Pay: hundred fifty dollars and no cents
PAY CITY OF PORT ST LUCIE UTILITIE
TOTHE PO DRAWER 8987
ORDER OF PORT ST LUCIE, FL 34985-8987
1100DOO 2 90 3 C3111 1:0 L I 2D L S 3 9i:DO 2 2 200 L8 2 L L110
52-153
Ti-2 ME
AMOUNT
$`*****450.00
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