HomeMy WebLinkAboutBuilding Permit Application (2) PLANNING AND'DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300.VIRGINIA AVE
FORT PIERCE,FL 34982
j . (772)462-1553 Fax(772)462-1578
i
PERMIT RENEWAL REQUEST
PERMIT NUMBER: I Le)q: 0'50 ADDRESS: $ k ��0.�
I
11 ►-�Qc ti� ��.0 ,am requesting that the above per nit.be renewed. I
understand at I must schedule and pass all required Inspections for the permit to be f haled. 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
i
i
OWNERMLDR OR tONTRACTOR SIGNATURE DATE -
i
Print Na
i
STATE OF FLORIDA
COUNTY OF M o r l
ACKNOWLEDGED BEFORE ME THIS (_Sk' DAY OF. 20 S
WHO IS PERSONALLY KNOWN TO ME X OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of VVQrt lK
[EE�(4; e oI FloridaG 004296SIGNATURE OF NOTARY
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
I — '
is
I
I