HomeMy WebLinkAboutBuilding Permit Application •
PLANNING AND DE'V'ELOPMENT SERVICES DEPARTMENT •
OU NTY `r. BUILDING AND CODE REGULATIONS DIVISION
r. ►, r.• r. R•:•• 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
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PERMIT NUMBER: I9 ` ON I ADDRESS:S(0O DU--CUA
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i, VY u ,am requesting that the above permit be renewed. I
understand that I must schedule and pass all required inspections for the permit to be 1 haled. 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. „
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OR OR CONTRACTOR SIGNATURE D E
Print Name
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STATE OF FLQlip&
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COUNTY OF I VV
ACKNOWLEDGED BEFORE ME THIS 4 DAY OFtiC fl bx ' ,20 I
BY (n V\31 \[Xi WHO IS PERSONALLY KNOWN TO ME ,V ,OR
HAS PROVIDED AS IDENTIFICATION.
rTA F FLORID ty of .. _.. i
At CRYSTAL A QIIEV�DQ
SIGNATURE OF NOTARY h*.-EAALL COMMISSION*FF904048
''''RES July 31.201*
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FOR OFFICE USE ONLY:
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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=8113"75(renewal fee)
Revised 7/21/2014
E0./E0 39dd N3IW3Nd 1760769ZLL LE:II 8TH/SZ/60
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