HomeMy WebLinkAboutWhite_Renewal Request Permit 1604-0522_ --PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUT- LDING AND CODE REGULATIONS DIVISION
2380 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NCIMBER: IVP A V �iO3 s,DDRESS: 8 (JV V CX.�i/ 1 r• / /
am requesting that the above permit be renewed. I
understand that I must sch lP and pass all requited inspections for the permit to be finaled. Further,
understand that this is a ONE TME RENEWAL and the permit shall expire should I not receive a
passing inspection d g any six month period d ` the renewal period.
r Justification =PSS �.z ��C� 77-Q J9,
13
OWNER/BLDR OR CONTRACTOR SIGNATURE DATE
_ krn IV) SA
Print Name MRLMOLEI
'gam: GpmmissW # GG 2081—
kApr117, 2$22
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STATE OF mt�
FLORID 1
COUNTY OF ln _
ACKNOWLEDGED BEFORE ME THIS DAY OF r 20
BY Kim lu i SUS __ WHO PERSONALLY 1240 TOME , OR
IiAS PROVIDED
AS IDENTMCATION.
STATE OF FLORIDA, County of �
S1bKXfW OF NOTA10 $FAQ
FOR OFFICE USE ONLY:
Number of Open Inspections: _
Total Inspections:
(Divide open by total to get % ofopea inspections)
Percentage:
Original permit fee: x % open = $ R oval fee
Example: [15 divided by 23=.6.5(%j,, $175(permit fee) x.654113.75 (renewal fee)
Revised 7/21/2014