HomeMy WebLinkAboutPERMIT RENEWAL _ PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION RECEIVED
REC
2300 VIRGINIA AVE
-- -- FORT PIERCE,FL 34982 AUG 1'9.Z�ZO
(772)462-1553 Fax(772)462-1578
ittln Department
?VE County
PERMIT RENEWAL REQUEST
Permitting Department
u r v ` St.Luct County
PERMIT NUMBER: ��C��a' \�� ADDRESS: 63� R P�•`t'(��Y �d. �O N �of v— V
I, Gad�el 0 n ,am requesting that the above permit be renewed. I 7 A $ L
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
DR OR CONTRACTOR`SIGNATURE DATE
S1k�e-k10 --� l .11l d 'LYl'�'n
Print Name v
STATE OF FLO DP[
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS _DAY OF 20_Zo_
BY M e
Wk�HO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS IDENTIFICATION.
STATE OFFLORIDA,CBuntyof KAREN S. NiELSEN
State of Florida-Notary Public
Commission # GG 207484
SIGNATURE OF NOTARY SEA OFfI My Commission Expires
June 12, 2022
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
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