HomeMy WebLinkAboutPermit renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
K W810111 W' BUILDING AND CODE REGULATIONS DIVISION I?
2300 VIRGINIA AVE FCF
_ FORT PIERCE,FL 34982 A qPM �FQ
(772)462-1553 Fax(772)462-1578 P, 8
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PERMIT RENEWAL REQUEST Com
PERMIT NUMBER: IV-00(D5- ADDRESS: �w ^� `�' es np
I, }�Q d s ,am requesting that the above permit be renewed. I 3 H_L Q
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
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OWNER BBLDR OR CONTRACTORSIGNATURE DATE
L �(� Noss'Ql/r
Print Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE M�E�THIv/S ZDAY OF
BY ��SFi�i¢ /� /ZelYiiL/ WHO IS PERSONALLY KNOWN TO ME_ ,OR
HAS PROVIDED // AS IDENTIFICATION.
STATE OF RID o ty of RICHARD F.KREBS
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Notary Public-State of Florida
SIG TURE or NOTARY SEAL ' Comm'.Exps�ion 1t s A r 26,2
My Comm.Expires Apr 26,2021
y •idthrough National Notary AS
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