HomeMy WebLinkAboutPermit Renewals r
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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
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PERNHT NUN BER: `�%®0�/ ADDRESS:., �E lr 1/ /l t (�1,e4s-6`
I, � �d��.--� ,am requesting that the above permit be renewed. I
understand th t 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 �zw d-.'y . /�!L�IJ/
O LDR OR CONTRACTOR SIGNATURE DATE
kwo ne lu�")
Print Name
STATE OF FLORIDA { 1
COUNTY OF
II ACKNOWLEDGED BEFOREXE THIS DAY OF ``� 20
BY /" A^"7 ge Ro'Jj!a,AJ WHO IS PERSONALLY KNOWN T0A1E,1 OR
HAS PROVIDED AS IDENTIFICATION.
T TE OF FLORIDA,Co my of _
Public State of;* da
VincerY nt Cornefl Gaskiin
MY.Commission GG 336745
SIGNATURE OF NOTARY E n Expires 05/25/2023
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
I4 (Divide open by total to get%of open inspections)
i 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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