HomeMy WebLinkAboutPermit Renewal ® •
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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT ri
COUNTYBUILDING AND CODE REGULATIONS DIVISION
F L 0 R I ,D"tr 2300 VIRGINIA AVE
Imummisimmor FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
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PERMIT NUMBER: 1504 o ADDRESS:, \\--), Pay 1 V Inn
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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 inspectiin during any six month period during the renewal period.
Justification at,` o f fz S�w�744-,( •r4 Sf.,(If T/, u u lav "
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OWNER/BLDR OR CONTRACTOR OR SIGNATURE DATE
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Print Name
STATE OF FLORID r r
COUNTY OF T Lace,
ACKNOWLEDGED BEFORE ME THIS 0 DAY OF ,20 l�
BY 00n CCAAart WHO IS PERSONALLY KNOWN TO ME ,OR
'HAS PROVIDED F- L J AS IDENTIFICATION.
STATE OF FLORIDA,County of � ,
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�� ; �a., ELLEN VAUGHN
SIG REO ARY SERI Stat e of Florida-Notary Public
Commission #GG 270079
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;`9VI,��0° My Commission Expires
__�_w _—_---------_--- October 23.,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