HomeMy WebLinkAboutPermit Renewal P Lvm to 1 JJ) 0 Baa-oats
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
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: BUILDING AND CODE REGULATIONS DIVISION
E 1. o. R I'Ti.A - 2300 VIRGINIA AVE
111111111111111111111111111111 FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 E CFjVFo
• PERMIT RENEWAL REQUEST Perm/tun 18
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PERMIT NUMBER: 1-'7 S*— r7 ADDRESS: 1`g5 "Ill1� � / . 4' ) ph�,IL,
am requesting that the above permit be renewed. I
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unde�"" • at ' �u t sc e.u e 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 ; ,i,_ 2 I ' AV / i -
•
0 ►s=-. t0.'•_: ' RACTOR SIGNATURE DATE
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Print ame .
STATE OF FLORIDA
COUNTY OF St- L.0 CI C
ACKNOWLEDGED BEFORE ME THIS IR DAY OF BOJ ,20 tr
•
BY (- S •siC‘ty .`\ WHO IS PERSONALLY KNOWN TO ME OR•
HAS PROVIDED FL ) L , AS IDENTIFICATION.
STATE OF FLORIDA,County of ,5 k LU"(,i Q
./e.- ;dip,,,, ELLEN VAUGHN
.0� °ee; State of Florida-Notary Public
SIGNATURE OF NOTARY �� • SEAL _, n'L-V
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Commisaio #GG 27,0079
MyComrit tan•Ex fires
FOR OFFICE USE ONLY: c /�
Number of Open Inspections: /9 ( ' W Cd f Pi uN,bA it I
Total Inspections: / ,
(Divide open by total to get%of open inspections) .
•
Percentage: �d
Original permit fee: x%open = $ -'IBJ Renewal fee •
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014
r______. .....-----=--------1
irt ELLEN VAUGHN
vkPuv= State of Florida-Notary Pn�1-�I.�*= Commission#GG 270II XA,` My Commission.Expi -10 October-22 2022