HomeMy WebLinkAbout16100 PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONSDIVISION
2300 VIRGINIA AVE
FORT PIERCE FL 34982
(772)462-15,53 Fax(772)462-1578'
PERMIT RENEWAL REQUEST
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PERMITNUMBER: 1610 �000L ADDRESS. :7/o. 3
1, Kati n s .
n ,,am requesting that the above permit be renewed. 1
understand that I must schedule ands 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 1 not receive a
passing inspection during any six�montth period during the renewal period.
Justification L:_46-k Y►er t`V �R' L- vl
7
OWNER/BLDR ONTRACTOR SIGNATURE , ATE
Print Name
STATE.OF I'LOR.�I
COUNTY 01 `
x
L
OREME TH1SAC Y OF 20�. { -
i3Y WHO IS PERSONALLY KNOWN TO ME,
OR
HAS PROVIDE �y r AS IDENTIFICATION.
STA FLORIDA Cun of
OMAS H.DABERRO
NOTARY PUBUG
'Sl: ATUR>rWNDTA oan
STATE OF FLORIDA
coft*FF128494
Exgr B!J?D1'8.
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get"/ol`open inspections)
Percentage:
Original permit fee: - x%open = $ Rene%%"al fee
,Example: [15 divided by 23=.65(%)] $175(permit rce)%.65=$113.75(renewal fee)
Revised M)1,014