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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
. BUILDING AND CODE REGJLATIONS.DIVISION
OLTIVTY 2300 VIRGINIA AVE •
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 4 2 �.®
• PERMIT RENEWAL REQUEST p§�y oe ?8�®
ed�
PERMIT NUMBER: 0-O '6 - o J)` ADDRESS: '460 t-u, c.vl q •, re K. `Z
I,JU fry 0 /I/-J A4P fd z, hef fi Cam requesting that the above permit be renewed. I
understand that I must schedule' 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 rriul•AAtir pekiod-durirg th2 renewal rjerk!od__ ._ _ _
Justification_r'\107 3)/, ,JA"
111 q-
OWNS' 'LDR OR CONTRACTOR SIGNATURE DATE• C
Print Name
STATEOF FLORIDA
COUNTY OF t G k V.k1) •
ACKNOWLEDGED BEFORE ME THIS C DAY OF f ,20 \ 0 0
BY (rf-Af...e.- 17` WHO IS PERSONALLY KNOWN TO ME ,ORG(i)4
• '^�/
HAS PROVIDED F AS IDENTIFICATION. tv(f"
STATE OF FLORIDA,County of ' ° `_`�_t u lk\ ' kl?
SIGNATURE OF NOTA t ,.. ._ ' ,,o Z
•+; COMMISSION aR FF8�4144
EXPIRES May 22,2020
(40713D0-01b3
------------_-- ---_--___---- F rL.'
FOR OFFICE USE ONLY: 1
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
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