HomeMy WebLinkAboutPermit Renewal Request PLANNINGBUILDING AND CODE R�GULAT ONS DIV SIO TNIENT
2304 VIRGIPIIA_AVE
- --- - FORT PIERCE„FL 34982
(7721-462-1553 Faz(772)462-1578
FERNIIT REN .:AL REQUEST
PERMIT NUMBER., .SGC:._t7/I-0/$Jr _ _ ADDRESS: �_gbg Wi�L�GR '. ._GONG. 0
r, Stiaunna LASam-reques ` g that the above permit be renew . I
understand that I must schedule and pass 411-requireci ns for the permit to be=final Further„I
understa6d'thatthis is-a.ONEXIVIE.RENEWALand.theperml 11 ex iresh :notreceive,a;
passing inspection during.any'six month period.dtzring.the.renewal peno
Justification orwriPr Aqrt h sched I ;nsMMIIn, lost' pe m f-
i X1=1 g-19 -
OWNE"LDR OR CONTRACT.,OR..SIGNATURE PATE
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shaunr�t�: Luks
Print.Name
STATE.OF FLO A
COUNTY"OF :. :
10
ACKNOWLEDGED BEFORE ME THIS .DAY OF 20
By G = � _WHO i5 PERSONALLY KNOWN TOME x OR
HAS PROVIDED: AS-IDENTIFICATION. j
ST "TEO FLORIDA;County f Un
1
00 PI Notary Pubfic`State of Florida
Ashley.M AntonetG
SIGNATURE OF N Y- SEAL .My Commissron GG_(52970
.Ad Expires 10/1812021
I ,
-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(%)1 $'1,75(perinit fee)x..6S=Sl 13.7a(renewal fee)
Revised 7-1/2414
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