HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 o y 101,
P„ OG FrG
PERMIT RENEWAL REQUEST qd �o 1
PERMIT NUMBER: I-I l;�[ D ADDRESS:06 1-1Loq�lun
L
i, Z A'US Z2e 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
OWNERIBLQV OR CONTRACTOR SIGNATURE DATE
I ° A15 ZQCQK
Print Name
STATE OF FLORID
COUNTY OF54.
�d
ACKNOWLEDGED BEFORE ME THIS rnAY OF N)Mb. 20J&
BY n 1 1�� tA&j WHO IS PERSONALLY KNOWN TO ME (✓ ,OR
HAS PROVIDED AS IDENTIFICATION.
(SV OF FLORID 6, 0 f�� Uict1
11
`° COLEEN SULLIVAN
: :... s
-SIGNATURE OFT76TARY SEAQ": MY COMMISSION#GG071535
E=XPIRES 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(penmit fee)x .65=$113.75(renewal fee)
Revised 7/21/2014