HomeMy WebLinkAboutPermit Renewals qq TT ,vim PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
' ✓ BUILDING AND CODE REGULATIO17MI
CEIVED''
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• . 2300 VIRGINIA AVE
FORT PIERCE,FL 34982 D.
(772)462-1553 Fax(772)462-1NOV 0 3 2017
PERMIT RENEWAL REQingDepartment
cie.County, FL
PERMIT NUMBER: / O ADDRESS:___� 6 �'J �' 6 4
u, /545 ,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 F,4 Q r. rG �T
OWNER/BLDR OR CONTRACTOR SIGNATTURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF 6)e-
ACKNOWLEDGED
k.ACKNOWLEDGED BEFORE ME THIS 3 DAY OF Imo+OJ 20_
BY L 4�J t nc+ V b bg WHO IS PERSONALLY KNOWN TO ME - OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of �} 1— DEANNA MARIE GIVENS
` MY COMMISSION#GG 022023
EXPIRES:December 16,2020
SIGNATURE OF NOT Y %';;off FA(gonded Thor Notary Public Underwriters
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get%o 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