HomeMy WebLinkAboutPermit renewal formPLANNING 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: d ADDRESS:6�O5�3 �I rt}w.f Ad..A 705' r-L 3L[kf !
I, ._ icy es �- gr I M en-- c , 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 any six month period during the renewal period.
Justification CNDi4 ;/,Cj
ERBLDR OR�CCONT/RACTOR SIGNATURE
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Print Name
STATE OF FLORIDA
COUNTY OF ST= / u Ci +r--
7Lc�/ La o ;z c-)
DATE
ST-
ACKNOWLEDGED BEFORE ME THIS DAY OF .J u t , 20 r D
BY r]�� E' (y�/ JYJ M f" WHO IS PERSONALL KNOWN TO ME V , OR
HAS PROVIDED
STATE O FLORIDA, County of T L- U G/
,,M-NATURE OF NOTARY
FOR OFFICE USE ONLY:
AS IDENTIFICATION.
SUSAN WNTCNEGRO
••` Y AV `L�':
MY com4 vv5slON� k 3G 089099
Q ¢ �AEXNRThru A ES: Apriil 212021
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