HomeMy WebLinkAboutrenewal form _ PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
s • —
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 RECEIVED
PERMIT RENEWAL REQUEST APR �:3 2018
Permitting Department
St. Lucie County
PERMIT NUMBER: 1710-0395 ADDRESS: 2703 N Al A Apt H
I, Shyan WOjtczak ,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 Tenant has a very busy work schedule
4/20/18
LDR OR C&XTeACTOR SIGNATURE DATE
Shyan Wojtczak
Print Name
STATE OF FLORIDA
COUNTY OF '�- A i{�►Ca� 1��1 -ter'`— t�
ACKNOWLEDGED BEFORE ME THIS ---�j DAYOF . � 20X `Y
BY IPI Cq W�S V C 2'A kL WHO IS PERSONALLY KNOWN'TOME OR
HAS PROVIDED C 0 AS IDENTIFICATION.
STATE O FLORIDA,County of _� V 'a��L \��l�C) ;o�'"Y P6er FAZIA SEER,1,10
Notary Public St2ta ct r.
COY`My Comm.Expires AubKZ
SIGNA OF NOTARY SEAL %,;For:�� •' Commission FF 1444�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