HomeMy WebLinkAboutPermit renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
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j - BUILDING 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 st �o� S?O�
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PERMIT NUMBER: AC(6-0(QADDRESS:
1, �n15 Z(Lr t0-1<' ,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/BLUR OR CONTRACTOR SIGNATURE DATE
finis ZaceK
Print Name
STATE OF FLORID
COUNTY OF � V�)
ACKNOWLEDGED BEFORE ME THIS QnAY OFNJONQYY)b(�rf- 20J&
BY _t 1 1� WHO IS PERSONALLY KNOWN TOME f✓ ,OR
HAS PROVIDED AS IDENTIFICATION.
IGNATURE
OF FLORID , o f ��. UUP
-49�►"":`4B., COLEEN SULLIVAN i
MY COMMISSION#GG071535 i
OF ARY SEAL = . ��
''r �q ' 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