HomeMy WebLinkAboutSLC PermitPLANNING 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
PERMIT NUMBER: f 10 q - d) U � ADDRESS: 3%00 IV' A-1-A -A 114
v''XS 6 q'S AA es , am requesting that the above permit be renewed. I
understand that I must schedule and pass all required inspections for the permit to be f naled. 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 �o{nt/h� period during the renewal period.
hLf! v ��• 1[1 1 .
Justification s n
7 b -12- L)
ER/BLDR OR
ICONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF ST 1-(4C/e— p �`
ACKNOWLEDGED BEFORE ME THIS / a DAY OF 4J Lt/7 e-- , 20 aZ 9
r
BY � r/I'!7 er O I
S PERSONALLY KNOWN T E 4-- , OR
. �G�� e=S ...
HAS PROVIDED AS IDENTIFICATION.
STATE F FLORID County of SUSANlON7ENEGRq
Ml' 0091MISSION # GG 089099
°ccXP1RS:A ri12.2021
IGNATURE OF NOTARY F ¢s
'.0 FL
_�,,,,a� ru NoEary Public UqCferwnlars
---------------------------------
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 7/2I/2014