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HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT BUILDING AND CODE REGULATIONS DIVISION 2300 VIRGINIA AVE FORT PIERCE,FL 34982 j (772)462-1553 Fax(772)462-1578 ' PERMIT RENEWAL REQUEST PERMIT NUMBER: ADDRESS: 10(.$o S 6C4-Q)n, !/n # r05 k i c(4*U t 6e1o,,V1N am requesting that the above permit be renewed. I understand that I must schedule and pass all required inspections for the permit to be finaled. Further, I understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a passing inspection during any six month period during the renewal period. j Ju 6A, 10 OWNERBLDR Oj�R�CONTR,XC�TOR SIGNATURE DATE Print Name STATE OF FLORIDA COUNTY OF -!+S ACKNOWLEDGED BEFORE ME THIS DAY OF fy")L,, p f, ,20 WHO IS PERSONALLY KNOWN TO ME OR HAS PROVIDED �3�0 SS2..`�S ©$ ,tom AS IDENTIFICATION. ASIAVM FLORIDA Countyof G, � Y lA AHNp iN AT�1'asida Public tot 2018. Exgtres Uec 20, OFNOTARY SEAL 1,11 Comm• q.i77249 v Gotnmission Assn. - ttationatNotaty I, i '��`"•=mss, gondedlhtou9���, 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 021/2014 r