HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
F L O R 11 :n A 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST c'Po,, d,
PERMIT NUMBER a. --1,44.3,- ADDRESS: k)3 5RA.r i ('fl (
,am requesting that the above permit be renewed. I
understand that I must sclke lule and pass all required inspections for the permit to be fmaled. 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 L k+,
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1ZOWNER/BLDR OR CONTRACTOR SIGNATURE DATE
Print N. a
STATE OF FLO
COUNTY OF LLG e.
ACKNOWLEDGED BEFORE ME THIS I04DAY OF flO �.L..., ,20
s �
BY 4 o h ) \ l WHO IS PERSONALLY KNOWN TO ME & ,OR
HAS PROVIDED AS IDENTIFI A •
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ATE OF FLORIDA,Count'. ` .. -�, ;` `,��p4PpY PUB(C; DEBORAH RUSSELL
g ; nZ _ Notary Public-State of Florida ,
1�4 ,�� _ / °• Commission # FF 179630 r
:N a Ii1Jll •oc�
, 'c' My Comm.Expires Nov 30,2018
SIGNATURE OF NOTARY ?� ''4%SAL *.,_
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