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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
-,., BUILDING AND CODE REGULATIONS DIVISION
0 2300 VIRGINIA AVE
- FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: Ic�O$ hZy1 ADDRESS: ZZ i&.F- V1-:;-1-4 'aL (Jw a zo(o
1, C-64am 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 A foetw— -tU I
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LIR40R CSIGNATI URE DATE
1 G A4-,1
Print Name
STATE OF t FLORID
COUNTY OF �
ACKNOWLEDGED BEFORE ME THIS �7 DAY OF 20
BY ` `�� ER ALLY KNOWN ME OR
HAS PROVIDED A' NTIFICATION.
S IR1.Yp,
STATE OF FLORIDA,County of ,c-
�� Notary Public
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SIGNAT F RY ,>rAl'" �p0 808(f,Comm EXon Ff23 Florida
dthr Pires 930
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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 1
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