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PLANNING AND DEVELOPMENTS
DEPARTMENT
BUILDING AND CODE REGULATION DIMMoun®:), apnj 'IS
• 2300 VIRGINIA AVE 4 U a t.Uja 2 d a(j l�D o��e 1,U.t a
FORT PIERCE,FL 34982 d
(772)462-1553 Fax(772)462-157
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PERMIT RENEWAL REQ 3
PERMIT NUMBER: ` "` 0/ O30SADDRESS: � !0 / _`
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I, i�CAt4-2fLPA -k - C�,IYio ,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
O RBLDR OR CONTRACTORSIGNATUREDATE
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Print Name
STATE OF FLORI
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF 20 U
BY /`Ji' CL p) OHO IS E NALLY KNOWN TOMEOR
HAS PROVIDED �/► C - AS IDENTIFICATION.
STATE LORIDA,County of
.%rr°i''••, AUDREY B.HUMPHREY
SEAL _ : MY COMMISSION n FF 17472
SIGNATURE OF NOT A` = EXPIRES:March 6,2019
Bonded Thiu Notary Pubs Undenwiters
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