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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
PERMIT NUMBER: O) �--® f
ADDRESS:200— R �- 02, -C E f
am requesting that the above permit be renewed. I � 1
uilderstand that I must scKedule 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
vol.el 30C.J,�2 z
OWNER/BLDR OR CONTRA TOR SIGNATURE DATE
LL C7 dl C4 '0 5a- &L2�'117
rint Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 20
BY tie n 01 r Q WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED C AS IDENTIFICATION.
STATE OF FLORIDA,County of
SI 7FuARE O AR SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections: ���crt -
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