HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTYBUILDING AND CODE REGULATIONS DIVISION
- 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST P
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PERMIT NUMBER: I -! "l ADDRESS. 101 5k 5• 0keao \ .
i, nIS Za ceV, —, 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
OWNER/BLEW OR CONTRACTOR SIGNATURE DATE
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Print Name
STATE OF
COUNTY OF FLORIDA,.,j d
ACKNOWLEDGED BEFORE ME THISJ�nAY OF JQCWMber 20_1&
BY �1 tff-001 WHO IS PERSONALLY KNOWN TOME 1,� ,OR
HAS PROVIDED AS IDENTIFICATION.
S"GARY
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GOLEEN SULLIVAN
SEA y. MY COMMISSION#GG071035 4
EXPIRES February 09.2021
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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