HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
r, BUILDING AND CODE REGULATIONS DIVISION
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f 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER:/ J V ADDRESS: I�r 2 36 SE -VA �T. R�.eT �L-
1, CAM(LLC K)S O Ai ,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
passinginspection during any six month period during the renewal period.
Justification
OWNF LDR OR CONTRACTOR SIGNATURE DATE
CAM r/-L6 d. J opoisON
Print Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE
TME THIS_ _DAY OFj-r'I
l Gz 20�
BY 1-n IZ c� coJ l�j4 n1 1\"O IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED )) AS IDENTIFICATION.
ST E OF FLORIDA,County ofA,
SIGNATURE 0 OTARY SEAL �g'"Yrr �, AUDREY R HUMPHREY
*c •`- MY COMMISSION#FF 174772
y EXPIRES:March 6,2019
pf t Bonded Thru Notary Public Undewitars
FOR OFFICE USE ONLY:
Number of Open Inspection's'.
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 7/21/2:014