HomeMy WebLinkAboutPermit renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
•
• R I D A 2300 VIRGINIA AVE Q
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 10�,.�� *0' O
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PERMIT RENEWAL REQUEST IGcP oP�a,
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PERMIT NUMBER: ADDRESS: A-CC4 f)\jC' . J'
1'. Zo r P ,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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MVNER/BL@V OR CONTRACTOR SIGNATURE DAYE
DWA15 ZaceK
Print Name
STATE OF FLORID
COUNTY OF e ��
ACKNOWLEDGED BEFORE ME THIS °bAY OF N)CX4r1 1 Nb6V- ,20A&
BY WHO IS PERSONALLY KNOWN TO ME i✓ ,OR
HAS PROVIDED AS IDENTIFICATION.
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FLORID , o f . OF
''"`Y' COLEEN SULLIVAN
E OF ARY �, dam= MY COMMISSION#GG 71
SE LXPIRES 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