HomeMy WebLinkAboutPermit Renewal To:7724621578 ;7724618722 # 2/ 3
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
s
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMITNUMBER:I 0?,0037- ADDRESS: )0G00 S
Hensen ca�h,l"L 3�9s'7
1,Mme_. f- SrL g?e--,r 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, 1
understand that this is a ONE TIME RENEWAL and the pen-nit shall expire should I not receive a
passing inspection during any six month period during the renewal period.
Justification / 'Totem c /7 Ot.�J�7 r
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CR/BL RD��R COONTR�ACTOR SIGNATURE DA E
. TA'w e. r• (rr�m cs
Print Name
STATE Of FLORIDA
COUNTY Or_S'T�.LCG/tom
ACKNOWLEDGED BEFORE ME TI I1S42LL__DAY OFa-rG 20
BY �_t,ti �� WI.10 IS PERSONALLY KNOWN TO Mrf-,OR
HAS PROVIDED AS IDENTIFICATION.
STATE 7 FLORIDA, unty oI ST 4
SUSAN MONTENEGRO
fif N TURF OF NOTARY MY COMMISSION#GG 089095
/ 5GA ; P F,(PIRES;April 2.2021
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--------------------------.W.. --------------------- __--------------------
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)
Revlsccd 7/21/2014