HomeMy WebLinkAbout2002-0059-RENEWAL-REQUEST11 ill"i 11111,5111! 1151
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT NUMBER: ® O®
I, eQ bjOrf0 (S&4 chC7-- , 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,
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 -W n c'�u (e- i naA v)'SPEGi-� 6/1
OWNER/BLDR OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORIDA
COUNTY OF , L, r
ACKNOWLEDGED BEFORE ME THIS DAY OF e 4:,f-, , 20
BY n Ho is PERSONALLY KNOWN TO , OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, County of p C J e-
ZpR Aaron Hallich
NOTARY PUBLIC
SIGNA OF NOTARY ESTATE OF FLORIDA
{
Cornm# GG951577
/NcE ��1� Expires 1/27/2024
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