HomeMy WebLinkAboutPermit Renewal 05/08/2019 13:04 7723367879 FEDEX OFFICE PAGE 02/03
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY.••• .; BUILDING AND CODE REGULATIONS DIVISION
r,;I. PRIV ,i
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
•
PERMIT NUMBER: ` —04)1 ADDRESS: , ' c * L -'.. &(\-t.
I, ,am requesting that the above permit be renewed, I
understand that I must schedule and pass al]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 - k.,1,,
0 R/BLD• O ONTRAC eRSIGNATURE DATE
Print Name
STATE OF FLORIDA .
COUNTY OF •
ACKNOWLEDGED BEFORE ME THIS `—\ DAY OF \� ,20 1�
BY W.;•I0 IS PERSONALLY KNOWN TO ME. OR
HAS ' 'OVIDED AS IDENTIFICATION.
/ A i OF FLORIDA,County of • L)...>•.-
r , Adana Veneziano
_ ' NOTARY PUBLIC•
•A,,TURl3 OP NOTARY ' SEAL .� :_�STATE OF FLORIDA
; at-ze corm&54185814
E�s • Expires 211412022
FOR OFFICE USE ONLY: — -----
mD
Number of Open Inspections:
Total Inspections:
(Divide open by total to get%of open inspections) (\n l
Percentage! 1 V
Original permit fee: x%open S Renewal fee
Example: [15 divided by 23.65(%)] $175(pennit fee)x.65=$113.75(renewal fee)
Revised 721/2014