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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
• i BUILDING AND CODE REGULATIONS DIVISION .
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(771)462-1578
PERMIT RENEWAL REQUEST
SOPERMIT NUMBER: ADDRESS.
I,�Tanno_r 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 AA)i'Ad6W ct ble 1z Pul
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OWNERBLDR ORC TRACTdR SIGNATURE DATE
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Print Name
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STATE OF FLORIDC5)z 2,`a
COUNTY OF
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ACKNOWLEDGED BEFORE NE THIS DAY OF `' — 20
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BY fl n 1X WHO IS PERSONALLY KNOWN TO Iv1E ,OR m
HAS PROVIDED - AS IDENTIFICATION.
STATE 0 FLORIDA,County of
SIGNAIURE OF NOTAkY U SEAL
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(0/o)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7!212014