HomeMy WebLinkAboutPermit Renewal FeiV CIL
PLANNING AND DEVELOPMENT SERVI + DEPARTMENT
C?U 1 YBUILDING AND CODE REGULATIONS DIVISION
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;�:,� p",l'ri=,,�Lb rf►�::,�. 2300 VIRGINIA AVE
FORT PIERCE,FL 34982
11111151.8611811111161141r (772)4624553 Fax(772)4624578
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APR 1 2O PERMIT RENEWAL REQUEST �''';tii
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PERMIT NUMBER: 150 U — v 3�5ADDRESS: g lAIroefvi jit
1, YUi1 IQ 1 • DQ \1\ ,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 lacy_ O{ YVI(Y) n takt-\cn
(No -f it/ if
0 ER/BLDR OR CONTRACTOR NATURE DATE
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ap1' ncnne ,
Print Name
STATE OF FLORIpA, r r '
COUNTY OF ,-)t-
ACKNOWLEDGED
�BEFORE ME THIS I f DAY OF APA---- ,20 I
BY 5 pJ.fl(< De-/vIA WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED rte- Z) AS IDENTIFICATION.
STATE OF FLORIDA,County of
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�`0114, ELLEN VAUGHN
ofFlorida-NotaryPublic
mission #GG 270079
SIGNATU' OF NOTARY SEAL ='?al�oe�;: My Commission Expires
" "�� Oeteber 22
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
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