HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY
BUILDING AND CODE VIRGINIA
ALAVE IONS DIVISION RFcF���
• FORT PIERCE,FL 34982 *Ov
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: ADDRESS:uo _ CC
Z2C to_K -,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
O"ER/BLRV OR CONTRACTOR SIGNATURE DATE
finis ZaceK
Print Name
STATE OF FL��ORID��,I!'
COUNTY OF FLORIDA,.
J��AY ACKNOWLEDGED BEFORE ME THIS OF ,20j&_
BY � WHO IS PERSONALLY KNOWN TO ME t✓ ,OR
HAS PROVIDED AS IDENTIFICATION.
NGNATURE
OF FLORID , o f I rfelj •, '�}
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SULLIVAN
OF rqtn ARY MY COMMISSION#GG07153:
„. LXPIRES Febwary 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