HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
✓ BUILDING AND CODE REGULATIONS DIVISION
COUNTY 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: I�[l� 7 01 19 ADDRESS:1 3,0� lnl��(�•1
I, nm5 zaceK ,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
MVNER/BLRV OR CONTRACTOR SIGNATURE DATE
4.4
IXJ nI5 zacQ I` �O�n enr
Print Name
STATE OF FLORIDA, �
COUNTY OF;� iv
riot
ACKNOWLEDGED BEFORE ME THIS AY OF 20A&
BY 1n�� WHO IS PERSONALLY KNOWN TOME f✓ ,OR
HAS PROVIDED AS IDENTIFICATION.
IGNATURE
OF FLORID , o f CA(F
COLEEN SULLIVAN
OF ARY SL t"" '= MY COMMISSION#GG071535
'7 Ff` 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(penmit fee)x.65=$113.75 (renewal fee)
Revised 7/21/2014