HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
Mal 9 It 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: � ADDRESS: -�Ja /lII 7,i'/Z L//*!�`-Ju
I,�-DA AJ A)V "If) 'T--) l Y ,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
WNE' 'DR QIJNTRACTOR SIGNATURE DAT
tl
n °i Y;/G�JI
Print Name
STATE OF FL¢$(p�1 ,
COUNTY OF �C'huc.2�
ACKNOWLEDGED BEFORE ME THIS DAY OF 20
BYWHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED N� AS IDENTIFICATION.
SYATE OF FLORIDA,County of Q_ 1� 27 INNGG
EXPMDftWJW20.2022
. GNATURE OF NOTAR SEAL ,, ' ePubQoUnd�alter�
i
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
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