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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND'CODE REGULATIONS-DIVISION .
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
/ PL
PERMIT NUMBER: ( O�/';�ADDRESS: �-EQ 3 Pea gum D(\ f c okl f'(?A(e 345 1
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.
Justification
O. RBLDR OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
44 COUNTY OF I e-1
ACKNOWLEDGED BEFORE ME THIS I DAY OF ICY)'�/�C 4— ,20. )
BY AO_IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED AS IDENTIFICATION.
STATEPF FLORIDA,County of �
AUDREY B.HUMPHREY
+r r MY COMMISSION I FF 174772
EXPSIGNATURE OF NOT arch 6,2019
$RAi" r Bonded Th.IENotaM Pub underwr ters
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
0
(Divide open by total to get /o of open inspections)
Percentage:
Original permit fee: x%open = $ Renewal fee
Example: [15 divided by 23=.65(0/o)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014
MAR 15 2018