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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: o �v 0 ADDRESS: a V'U
I,�Jam1•-e 1 J T(`G nUSC 7 ,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
OWNERR OR CONTRACTOR SIGNATURE DATE
S
�ary\\
Print Name
STATE OF FLORID
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OFC:'-g 1 20
BY )• SWHO S PERSONALLY KNOWN TOME ,OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of
SIGN OF NO U SEAL
s
FOR OFFICE USE ONLY:
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#NOISSIWWOJ AW s,. •�,f
Number of Open Inspections: L4 Q(1tl
Total Inspections: �aNdW(1H'91�
(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