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PLANNING AND DEVELOPMENT:SERVICES`.DEPARTMENT
BUILDING AND CODE:REGULATIONS.DIVISION
s 230.0 VIRGINIA AVE'
FORT PIERCE,FL 34982 --
(772)462-1$53 Fax(772)462-1578. FAUG
EIVE D
PERMIT RENEWAL REQUEST
5 2020.
ST. Lucie County, Permitting
1'ERMITNN1triSER: I AD.DRESS; �H �: -
am,requesting:that the above permit be renewed. I
u.nderstadd that_I must schedule and pass all required inspections for the perm it to be fihaled:. Further;I
understand that this is a,ONE.TBIW RENEWAL and the,permit-shall expire should I not receive
p, g' p , g;. ysix month period during the renewal.period.
assu} Ins ectlon durin an
Justification Hwnc' �` -)ff" Las of.
OWNS DR.OR C CTOR:SIGNATURE DATE
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Print ale
STATE OF ELO ,
COUNTY OF
ACKNTOWLEDGED BEFORE ME THIS DAY OF 20
BY�} �. '" O IS PERSONALLY KNOWN TO MR ,OR
HAS PRO D AS IDENTIFICATION.
STATE OF FLORIDA,County of �
8�m, A Cli Q R3 Of Notary Puntic stato of Florida
SIGNATURE OF NOTARY SEAL. '� Amanda_P Sanderson,
-s, My C�Mmisston GG211256
*y a M1 Expires 0445f2022"
F.OR.OPFICE USE ONLY:
Number of Ope..n Inspections:
Total Inspections:.
(Divide open by total..to get%of open inspections)
Percentage: .
Original permit:fee: x%open S Renewal fee.
Example: [15 divided by'23=.65(%)1' $1.75(permit:feej x.65=$113.75(ranewal fee.)
Revised 7i2I,"20I4.