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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:AL ADDRESS:_- j 3 �Q lJJr �. 1)wkMj`zAXt
1, j' e,a do. 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 gdr AALq 713 HAt1S &u4k;Z- 4o214 , l(D5 f
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O RIBLDR OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OFbs�c,.A.
ACKNOWLEDGED BEFORE ME THIS 119 DAY OF QA.0 .20 I�
BY � }Z Y ` ^fid. WHO IS PERSONALLY KNOWN TOME ,OR
HAS PROVIDED' ►- AS IDENTIFICATION.
S OF FLORIDA,County ofX
OF NOT ,,,, LASHASNA INGRAM
Notary Public•State of Florida
?xu h,ty Camm. ;res Dec 20,2016
177249
FOR OFFICE USE ONLY: ery +� ►
Number of Open Inspections-
Total Inspections:
(Divide open by total to get%of open inspections)
Percentage:
Original permit fee: x%open = $ Renewal fee
Example: 115 divided by 23=.65(%)3 $175(permit fee)x.65=$113.75(renewal fee)
Revised 7!21/1014
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