HomeMy WebLinkAboutpermit renewal f
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST
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PERMIT NUMBER: ADDRESS: 155C) (0 ►1'� t
I, 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 722 A S/C/
O mR/BLDR O41IT4;ITO�RSIINATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF Sfi ` \x
ACKNOWLEDGED BEFORE ME THIS DAY OF 20
BY WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED �' _ AS IDENTIFICATION.
STATE OF FLORIDA,County of ��r �� kQ;+ -e `
pw' ELLEN. VA U G H N
State of Florida-Notary Public
SIGNATURE OFN ARY\ S '- Commission #GG 270079
0 ° My Co% mmission Expires
ilm October 22 2022 .
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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
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