HomeMy WebLinkAboutPemrit Renewal J .N _ � PLANNING AND DEVELOPMENT SERVICES DEPARTMENT,,,
BUILDING AND CODE REGULATIONS DIVISION NO` �o
- 2300 VIRGINIA AVE
FORT PIERCE,FL 34982 �9
(772)462-1553 Fax(772)462-1578 <oe�
PERMIT RENEWAL REQUEST
PERMIT NUMBER: � � i � l(` ADDRESS:I S lJ��� �1 ` At sq-
I, bein15 Zat(',01<- ,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
Dm� � I
RBL OR CONTRACTOR SIGNATURE ATE
l enA15 ZaceK
Print Name
STATE OF FLORID `
COUNTY OF_� �
nd
ACKNOWLEDGED BEFORE ME THIS J. AAY OF 9 ,20—L&
BY Dpmlb tmpl WHO IS PERSONALLY KNOWN TO ME 1/ OR
HAS PROVIDED AS IDENTIFICATION.
IGNATURE
OF FLORID o f ��, �..�uP
ti�"•t ` COLEEN SULLIVAN
OF ARY SEAL ? '
•'c MY COMMiSSIQN t1 GG071535
EXPIRES February 09,2021
------------------------------------ --
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