HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
® - BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE mi
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: I�Q Q ��� ADDRESS:
,I; o"� 5 0 ,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.
Justification1
4VN
ERBLDR OR CONTRAC OR SIGNATURE DATE
Print Name
STATE OF FLORI `
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS _DAYM 20_Z�'
BY,::];W5, '5, 'I D k,,jad WHO IS PERSO ALLY KNOWN TO ME r✓ OR
HAS PROVIDED AS IDENTIFICATION.
STATE 0 LORIDA,County of Y
",IRevery J.Proske
NOTARY PUBLIC
SIG RE OF N SEAL 4 STATE OF FLORIDA
Comm#GG262780
VAR Ir Expires 9/26/2022
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