HomeMy WebLinkAboutPermit Renewals d
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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: f / !K-0017 ADDRESS: (tel Z r ye ` ' L
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.
I Justification
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OWNER/BLDR OR CONTRACTOR SIGcN�ATURE DATE
PA's Lo �?o
Print Name
STATE OF FLO
COUNTY OF
ACKNOWLEDGED.BEFORE ME THIS C l DAY OF tJC. ,20a
BYC'�l'W � C`��_e WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED �w " AS IDENTIFICATION.
NSOF FLORIDA,County of �I&C—Q Y�ASiinNN 1$`Q`� +'I b
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TURFOF NOTARY *� Q MyY�6 +ss+h Na+op?1N��atYa
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FOR OFFICE USE ONLY:
Number'
umbeof Open Inspections: V v v
r
Total Inspections:
(Divide open by total to get%of open inspections)
Percentage:
Original permit fee: x%open = $ Renewal fee
I
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014