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PLANNING AND DEVELOPMENT SERVICES DOARTMENT
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.7, BUILDING AND CODE REGULATIONS;DMSXON
« 2300 VIRGINIA AVE
'.. .............. FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-X578
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PERMIT RENEWAL REQUEST
PERMIT NUMBER: l l�C )n^ .Q ADDRESS:
I ,am requesting that the above permit be renewed, I
un erstan t a mschedule ust scule an ss all required inspections for the permit',to be finaled_ Further, l
understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a,
i passing inspection during any six month period during the renewal period.
Justi 1 ' 11
OWNER/13LDR O CONTRACTOR SIGNATURE DATE
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Print Name
STATE OF FLWC1.
COUNTY OF +
AC QWLEPqD BIL ORE ME THIS DAY OF JoWnbU 20
B [ WHO I5 PERSONALLY KNOWN TO ME V OR
HAS PROVIDED AS IDENTIMCATIOIN.
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TATE OF FLORIDA, ou y aI
!Y' y ,A)&11NA L HOPKIN5C8NN&Ly.
MY COMMISSt UM 941411
eNATU1OFN0TART--- jD9'1RE$:Decamhat6,2019
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FOR OFFICE USE ONLY:
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Number of open Inspections:
Total inspections:
(Divide open by total to get%of open inspections)
Percentage: _
Original permit fee_ x%open ^ $ Rencwal fee
Example: [15 divided by 23^.85(6/6)] $175(permit fee)x.65-$113.75(rcncwal fcc) d
Revised 7/21/2014
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