HomeMy WebLinkAboutRenewalPLANNING 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: OM ADDRESS: 6U 7 NF F4uy,f 14AA -*gol (I-C(. r. N11.1
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 six month period during the renewal period.
Justification 71r, r.�-
C
ERBLDR OR CONTRACTOR SIGNATURE
J`6W�S F 5rf yyLe
Print Name
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STATE OF FLORIDA
COUNTY OF _� /_G!%•! fP
ACKNOWLEDGED BEFORE ME THIS DAY OF �] �L iI , 20 O')' o
BY a WHO IS PERSONALLY KNOWN TO MOR
HAS PROVIDED AS IDENTIFICATION.
STATE FLO , County
••t i.¢u SUSAN MONTENE0F1
IGNATURE OF NOTARY r . �n MY CQMMl5SI0N GG 4894�
c«• = EXPIRE.$:Wil2.2021 tens
%�4 ' g�dThsu 1So�ary Pubt'sC under+
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