HomeMy WebLinkAboutPermit Renewal I �
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY BUILDING AND CODE REGULATIONS DIVISION
FL OR DA 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
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PERMIT NUMBER: .1 (IQ 11'005 ADDRESS: iltP) PfDI RC
I, K(Xren- CbculKe( ,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 n�`4e—to l Q C C U p N in Po o I ,
OWNER/BLDR OR CONTRACTOR SIGNATURE DAT
Bcr k-kQA/
Print Name
STATE OF FLORID
COUNTY OF 99
ACKNOWLEDGED BEFORE ME THIS S DAY OF ' �� ,20 /1
BY I�C�t e(1 (l?�� WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED �_L _Lc( AS IDENTIFICATION.
STA FFL RIDA,CountyofG�� ;=o�PaYP`° ELLEN VAUG
„1*=State of Florida-Notary public
Commission #GG 270079
SIGN O TARP SE., �P,;,;;° My Commission Expire's
October 22, 2022
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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