HomeMy WebLinkAboutPermit RenewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
00 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)4 -1 Fax (772) 462-x 7
PERMIT RENEWAL REQUEST
PERMIT NUMBER: C� "`'� � ADD.RESS: L41 C� �V4 � 1-�\JQ
1, � 0.SG�� ... __.. , 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 sip month period during the renewal period.
Justification
OWIV.+'$LDR OR CONTRACTOR SIGNATURE
Print Name
STATE OF FLORIDA
CQUNTY OF S&1 RT L.,U OWL _
ACKNOWLEDGED BEFORE ME THIS � D
BY Jjtr50 0 S -TgDO n Et
DATE
DAY OF C-) CTt) 6 �"�` 120 ZO
WHO IS PERSONALLY KNOWN TO ME � , OR
HAS PROVIDED AS IDENUFICATION.
S"r.ii
FL RIUA, County
SI OF NOTARY
SEAL
I I I , - �-;� JASON COLVILLE
�.
ommisi n # HH 023495
Expires July 26, 2024
Bonded Thru Troy Fan Insurance -M&701
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FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide p by total to get % of open inspections)
P erc entage
Original permit fee: % p n
Renewal fee
Example; [15 divided by 23=.65(%}] S175(perrm't fee) x .65=$113.75 renewal fee)
Revised 7/21/2014