HomeMy WebLinkAboutPermit renewal request _ 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 Y/7 ADDRESS: / o� c )y 07--
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
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.�OWNER/BLDR OR CONTRACTOR SIGNATURE DATE
6 ))e c/ R,
Print Name
STATE OF FLORIDA � 1 . ��C•
COUNTY OF T
ACKNOWLEDGED BEFORE ME THIS _DAY OF 4414 lT 20
I
BY C9 L �T� C l�WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED � J�P� C AS IDENTIFICATION.
STATE OF FLORIDA,Co ty of
SIGNATURE OF N ARY SH ;`atP?YPp AUDREY B.HUMpHREY
MY COMMISSION#GG 300817
EXPIRES:March 6,2023
.'•FOF FISP:
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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