HomeMy WebLinkAboutPermit Renewalhcocv,Ul
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
0
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGIM AVE
....._...,'...._.._-....... _---..-...._....... FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERNIITNUMBER 170� 01 H ADDRESS: 3�0� S� S Rw.� `I �dl iicac
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I, U WIGS 0 rim 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 finaled. Further, I
understand that this is a ONE TIME RENEWAL and the permit shall expire should I not receive a
passing inspection,,iuring any six month period during the renewal period.
Justification is/m
9WNERR//BBLLDDRROR CONTRACTOR SIGNATURE
Print Name
STATE OF FLORIDA _
COUNTY OF - LGcG% P—
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ACKNOWLEDGED BEFORE ME THIS O DAY OF 20�
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BY zGlm eS G-/c-h/mP_C' wun SPFRSnNdTiVYNnAR.T Tn �Rt no
HAS PROVIDED - Ac TnT.'NTn:Tr ATrnr:
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STATE FLORIDA, owty of Is T✓ Z— u G/ /�
IGNATURE OF NOTARY pI
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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 .654113.75 (renewal fee)
Revised 7/21/2014
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MYCOMMISSION>< GG 089099
EXPIRES: Apnl2. 2021 4i
,nded Th ftary Pub�x Onde`milers 3,
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