HomeMy WebLinkAboutPermit Renewals j�
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
s
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)'462-1578
PERMIT RENEWAL REQUEST J
PERMIT NUMBER: I Gos" 00 3 ADDRESS: -5,30.E ��e• O. Y7es
i, o„ o r•.ti s ,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.
1 Justification
�t !S
O LDR OR CONTRACTOR SIGNATURE ATE
Glen //7o1�"LA 3
Print Name
I j '
STATE OF FLORIDA
COUNTY OF �• L u c r / qq
ACKNOWLEDGED BEFORE ME THIS�7_DAY OF �Jr�uGv�+ e,-
I 241
I I
BYJ,��JY1 `�6Y`�4S WHO IS PERSONALLY KNOWN TO ME OR
i
HAS PROVIDED �L- `bb� AS IDENTIFICATION.
STPT OF FLORIDA,C unty of +SSL „ Y
I `
LAS AIJNA ItIGF1AN1
�,aY X09% State o1 Fioritla
�P +�,., Ndtlary Public
Expires Dec 20,2018
49
N. TUREOFNOTARY IIA.• naQ ilommission 1772
=�r otar Assn.
oh;° Boned throeiJh National N Y
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 fel)
Revised 7/21/2014
I
ii
I
I I I'