HomeMy WebLinkAboutPermit Renewal Request 1111111111111111111 PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTYBUILDING AND CODE REGULATIONS DIVISION
F L. 0 1' 0 �.P ` 2300 VIRGINIA AVE
_ ----- ---- _a FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: In 0, 136M ADDRESS: 15b l pas() kb/es B LAA0
I, ,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. `` ��y
Justification ) 5 C orfp� r- 100 `,�- hi- GU G1 (io
/ /_ , /
�( iL.�, , - .� .) Oct I I q
OWNE' LDR OR CONTRACTOR SIGNA V ' DA E
Print Name
STATE OF FLORID,
COUNTY OF LiA a R.- �1 l q
ACKNOWLEDGED BEFORE ME THIS' /A,t DAY OF J ,20 ti
1
BY I--WI c 12"ky(v( WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED t P AS IDENTIFICATION.
STATE OF F ORIDA,County of c ' L1 C k
v C �' • ;2o�PaYP�a,, ELLEN VAUGHN
SIGNATURE OF NOTARY SEAL °, �SCce°f Florida-Notar
.,,.,� ,,� mmisslon # Y Public ,
me 270079
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��o� . MY Commleslon Expires
''�,nN` � tBer 224122___
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FOR OFFICE USE ONLY:
Number of Open Inspections 0
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