HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- BUILDING AND CODE REGULATIONS DIVISION
M11 19 1 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: / �(/ / ADDRESS: /;7y Xe 111rf gl,&-e IS'eae�h
1, wa� .5i- fh ,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 /moi/ %r/,�e c,
OWNER/BLDR OR CONTRACTOR SIGNATURE DATE
,"- 12
Print ame
STATE OF FLORlA
COUNTY OF �'.Ly e
ACKNOWLEDGED BEFORE ME THIS 36 DAY OF Q VN 20NA_
BY Q X ck W'%, S Vf"^, C WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED F t L AS IDENTIFICATION.
STATE OF FLORIDA,Count�ol ';� L u t '� DeMINA MARIE GIVENS
2' ` MY COMMISSION#GG 022023
EXPIRES:December 16,2020
SIGNATURE OF N ARY %;FUc F,o 9onde�BJq[P1oN Public Undentirle 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