HomeMy WebLinkAboutRenewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
•
- BUILDING AND CODE REGULATIONS DIVISION
_ 2300 VIRGINIA AVE y
FORT PIERCE,FL 34982 Off,
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST '°;��,,�
PERMIT NUMBER: I n ADDRESS:
I, Za c eK ,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
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OWNER/BLUY OR CONTRACTOR SIGNATURE DATE
DI EnnI5 MOCK
Print Name
STATE OF FLORIDA, `
COUNTY OF iv id
ACKNOWLEDGED BEFORE ME THIS °bAY OF 20_[&
BY 1 1� WHO IS PERSONALLY KNOWN TOME 1/ ,OR
HAS PROVIDED AS IDENTIFICATION.
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%GNATURE
FLORID o f :�a`:��gL•; COLEEN SULLIVAN
o: p
MY COMMISSION#GG071535!
lit) ;F ` EXPIRES February 09.20�
OF ARY S A�
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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