HomeMy WebLinkAboutPermit Renewal .. II
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RECEIVED
DEPARTMENT PLANNING AND DEVELOPMENT SERVICES DEPART
NOT 12 2619
- BUILDING AND CODE REGULATIONS DIVISION
MMUM2300 VIRGINIA AVE
FORT PIERCE,FL 34982 P9Pif11Ulflg Be partment
(772)462-1553 Fax(772)462-1578 �' 'L_l1@I@flflY
PERMIT RENEWAL REQUEST
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PERMIT NUMBER: f04(oe,ADDRESS: c� 2 1 V V bl"XI'e
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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 �� z ca- ear '?
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OWNERBLDR OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA ((
COUNTY OF 1�"Cie,
ACKNOWLEDGED BEFORE ME THIS DAY OF 0 20
BY KCAVIA/ WHO IS PERSONALLY KNOWN TOME OR
HAS PROVIDED 1 1 AS IDENTIFICATION.
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STATE OF FLORIDA,County of
ELLEN VAUGHN
�pRY PUB
4*_State of Florida-Notary Public
SIGNATURE OF NOTARY SEAL � .� Commission #GG 270079
7?`VoFuu��"':° My Commission Expires
"Ilk October 22, 2022111111
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
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Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014
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