HomeMy WebLinkAboutStroot_Renewal Request Permit 1505-0391NT SERVICES DEPARTMENT
""PLANNING AND DEVELOPME
BUILDING AND CODE REGULATIONS DIVISION
2M VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772)462-1575
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PERMIT RENEWAL REQUEST
,..f v V / 1�DDRESS: 7 �Qf% f�1r• G l 9
" + PERM[rr NUMBER:
1, 4ft6 T wnbi n f , am requesting that the above permit be renewed. I
understand that I must schedule and pass all required inspections for the permit to be fixaled. Further. I
a . , understand that this is a ONE TDM' -RENEWAL and the permit shall expire should I not receive a
passing inspect=1f0^5
g any six month period d the renewal period.
Justification
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OWNERBLDR OR CONTRACTOR SIG14ATURE
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Print Name
DATE
;pd1° AWLCommim #GG 208194
BondeG =Toy e. Las
STATE OF FLORID �pp���
COUNTY OF V& __ , 4
ACKNOWLEDGED BEFORE,ME THIS _Z -__ DAY OF { 120 j U
BY l lig lA� t S(JI __ WH0 PERSONALLY 17O TO ME , OR
w: f: !!AS PROVIDED AS IDENTIFICATION.
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}Hn�i STATE OF FLORIDA, Couaty
S! QA OF NOI SEAT.
FOR OFFICE USE ONLY:
Number of Open Inspections: _
Total Inspections:
(Divide open by total to get % of-opeu inspections)
Percentage:
Original permit fee: x % open = $ R ,-wv al fee
Example: [15 divided by 23=.6.5(%j; $175(permit fee) x.654113.75 (renewal fee)
Revised 7/21/2014