HomeMy WebLinkAboutPermit Renewals • s
_ PLANNING AND DEVELOPMENT SERVICES DEPARTMENT ..
t BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
f FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: SLC 180-9"6015 ADDRESS: 6Y6y O<&I4-vjS E&7,47F_s CT
I, Et L S oaf am L ew �S FZ a�r� l FC_ 3q9it b requesting that the above permbe 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 (INFc9,SEEV', oWNi2 QC—tAY
n •
OWNERBLDR OR CO TRACTOR SIGNATURE DATE
Print Name
f
STATE OF FL
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF �]I�f�(.LrL— 20D��
BY V 2.f i Lt u/1`5 WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED ( 0 P-i VY/S �t`Cry.-C�. AS IDENTIFICATION.
STAT FL 10A,County of Rom, Gizelle Reyes
�
Q°tp Ason NOTARY PUBLIC
I
SI OF NOT SEAL .2 -STATE OF FLORIDA
Comm#GG171261
El Expires 412412022
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