HomeMy WebLinkAboutPermit Renewal Request •
111,
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
C4UN +'° BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
— 11 FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: V-16 ' 5l y ADDRESS: 23 .
I, 0,1I`I S (421.z. ,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 •
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OWNE :LDR OR CONTRACTOR SIGNATURE DATE
CLc c4rqr,L Mx k h
Print Name
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STATE OF FLORIDA
COUNTY OF SN• 1.r t:C
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ACKNOWLEDGED BEFORE ME THIS 0; DAY OF OC tol►C C ,20 16
BY C 4+(161-o tl' tc M, Voclkova It WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED 101-01%, D f:vc(S L:C t n St AS IDENTIFICATION.
STATE OF FLORIDA,County of 6k LJ61ANGELO KARL GRISETTI
; -V' NotaryPublic-StateofFlorida I
i✓ 14,4- &]/'7d , _ nut Q€ Commission=GG 146115 :
SIGNAT!RE OF NOTARY ( S Fl, My Comm.Expires Sep 26,2021•
FOR OFFICE USE ONLY:
Number of Open Inspections: $ \50 ' as
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