HomeMy WebLinkAboutPermit Renewal, 2nd time, ok per D Harvey PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
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
PERMIT NUMBER: � �Do-%DRESS:
I, & w�� , 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 pe iod during the renewal period.
Justification
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OWNE LDR OR CONTRACTOR SIGNATURE DATE Print Name
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STATE OF FLORID
COUNTY OF ��,t_y e
ACKNOWLEDGED BEFORE ME THIS f DAY OF 20_p�
BY �� Qahm WHO IS PERSONALLY KNOWN TO MEy ,OR
HAS PROVIDED ��. _ AS ID
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STATE OF FLORIDA,County of C� L�(J�/� ?oFF�oP°:� mmisOf sori a NO e�P bli
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Y Comfip 27007,9 c.
SIGNATURE OF NOTARY / SEAL October 2, n.xPirl s
---------------------------------------------------------------------------------------------_------- - ------
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get%of open inspections)
Percentage: i
Original permit fee: I x%open = $ Renewal fee
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014 I
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