HomeMy WebLinkAboutPermit Renewals 02/21/2018 14:33 Off ice (FAX) P.002/002
PLANNING AND DEVELOPMENT SERVICES DEPART T
BUILDING AND CODE REGULATIONS DIVISIO
COUNTY
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1.578
C
PERMIT RENEWAL REQUEST
APr
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PERMIT NUMBER:.S'LC 1 O "4S8S ADDRESS:-QS �Q_d,Ii'1X[� Q
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 lsnaled. 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 morm periodTuring the renewal period.
Justification P&V /
ly(
O W��N^^ER/BL,, R OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FI,OftlqA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS 2� DAY OF
BY WHO IS PERSONALLY KNOWN TO ME y .OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF Munty of � V1,
=CAROLEA
AULSEN FF991106SIGNATUREOF NOTARY S Aly10,2020b.,ean
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