HomeMy WebLinkAboutPermit Renewals _ PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- BUILDING AND CODE REGULATIONS DIVISION
• 2300 VIRGINIA AVE
- FORT PIERCE,FL 34982 =RECEIVED(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: ( Xr6- (2O"0 ADDRESS: E
Lr14ecII, am requestinngg that the 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 ren wal period.
Justification — �C
O L R OR CO TRA OR SIGNATURE DA
Print Name
STATE OF FLORIDA.
COUNTY OF L V c
ACKNOWLEDGED BEFORE ME THIS DAY OF PP',Ck 1 20_&_
BY Lo t i
WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED S L VC�� �,� AS IDENTIFICATION.
STATE OF FLORIDA,County of S'�' • L G+ NA MARIE GIVENS
+ MY COMMISSION#GG 022023
Y EXPIRES:December 16,2020
SIGNATURE OF NOTA Y 'rF ,;�`;�. Bonded Thru NSWdubiic Underw ile+s
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