HomeMy WebLinkAboutUntitled PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
]WILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 10 O 03G 63 ADDRESS: I()60D S d Ct
I, IAA 1 doxj:L, (9cpoyW),� ,am requesting that the above pe-AiMe 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
(� V6 L
OWN B R OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF /sem
ACKN WLEDGED EFORE METHIS.-al DAY OF 201a—
t,
01pt, I
BY Y i P ONALLY KNOW TO ME OR
HAS PROVIDED AS IDENTIFICATION.
•��qV P�� ANGELA M 4UFF
STATE OF FLORIDA,County of Notary Public-State of Florida
o Commission#FF 234730
SIGNATURE OF NO RY SEAL I �oF� � My Comm.Expires May 27,2019
.;7 Bonded through National Notary Assn.
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FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections: I
(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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