HomeMy WebLinkAboutUntitled PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
-.,1 BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
~-. FORT PIERCE,FL 34982
(772)462-1553 Fax - 578
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PERMIT RENEWAL REQUEST
PERMIT NUMBER: L6(1 —C)O3 ADDRESS: oO�� S
I, ,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.
Justification J
�:N\EIR/BL/bR OR CONTRACTOR SIGNATURE DATE
M 1��-A2� ("Mo w
Print Name
STATE OF FLORIDA
COUNTY OF ��L–Lc -e-
1
BEFORE ME THIS d 1 DAY OF 20�
BY C___Aa.� If�W'H'Q IS P O ALLY KNOWN TO ME OR
HAS PROVIDED IFICATION.
S TE OF FLORID County of r '�
ANGELA M:1UFF
1PR �B�4
SIGNATURE 0 OTARY , , Notary Public State of Florida
° commission#FF 234730
My Comm.Expires May 27,2019
'' ° °`' Bonded through National Notary Assn.1
-----—---------------------------------------------------------------- -------------------- ---_-- —d- -- -----------------
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