HomeMy WebLinkAboutrenewel request i
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
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2300 VIRGINIA AVE
FORT PIERCE,FL 34982
' ^ (772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER:16V- 170(Ja3 ADDRESS: zo .6c 96.(l A
I, 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 inspecti n during any six month period during the renewal period.
Justification a a'9
OWNER/BLDR TRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF • LV c
ACKNOWLEDGED BEFORE ME THIS , DAY OF F els' ,20 `A
By �q+"aJ <•��0� WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED AS IDENTIFICATION.
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STATE OF FLORIDA,County of S T. �— c�4my
nt;4NN�l�livvte.fllaial� . I€
CON-1kilmoN P.Go 0KNIS
FJCFIREui G eAft'.ar 10,20) r'
SIGNATURE OF NO RY ":;qFF�� ' Bonded 7hni Na6FAIsFalic Uridenvlq�r'j
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
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Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014
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