HomeMy WebLinkAboutPermit Renewals May 0718,01:41 p Veterans F 4"72650 p.2
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
bitBUILDING AND CODE REGULATIONS DIVTSION
• 2300 VERGIN14 AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PER1,IITNUMJBER.-,5t—C 1768— 6337- ADDRESS, 'r0
1'. am requesting that the above permit be renewed. I
understand that I must schedule and pass all—requiredinspections for the permit to be finaled. Further I
understand that this is a ONE TIME RENEWAL and the permit shall expire should 1 not receive a
passing g inspection durmp any six month period during the renewal period.
A o
Justification Lc>s-,, t, i
OWNtR/BLDR OR CONTRACTOR SIGNATURE 'DATE
Print name
STATE OF FLORIDA.
COUNTY OF c,7-�Lvci-C
ACKNOWLEDGED BEFORE ME THIS S DAY OF 20
BY (C�i n.07L & 441rlk- WHO 19 PERSdALLY KNOWN TO NIE OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County C f -C
A R I
SIGNATURE OF NOTARY
S TYZ
#GG 013423
FOR OFFICE USE ONLY: ed tAx"
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Number of Open Inspections:
Toil Inspections:
(Divide open by total to get%of open inspections)
Percentage:
Original permit fee: x%open = S Renewal fee
Example: [15 divided by23=.65(!/o)j $175(permit fee)x.654113.75(renewal fee)
Revised P21/2014