HomeMy WebLinkAboutRenewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
R 2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 0 0 2— - ADDRESS: 50q I ly. . t )w A * `-fo3 t;,+ nj c,,ce f=I 31611
understand that I must schedule an .. am requesting that the above permit be renewed. I
d 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 L i f r permi-�
ER/BLDR OR CONTRACTOR SIGNATURE DA E
Print Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS ,2< DAY OF Zlu'n _ 2012-6—
ram"`
BY G- e S' WHO IS PERSONALLY KNOWN TO ME, OR
HAS PROVIDED AS IDENTIFICATION.
�ilY
�I �/ Yl li'+Il+ V �7�1�61YIG3\V7TfV
STATE O FLORID , County of _tr 11 MY 00%JISSION ft GG 089099
SPIRES April2.2021
' '� FOF €�o;:�� �gnded �hsu Notary Public t}ndanvs�te�s
IGNATURE OF NOTARY SEAL
i
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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 7/21/2014