HomeMy WebLinkAboutPermit #2005-0323 Renewal RequestPLANNING 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 NUMBERA M-5 r o✓ 3 ADDRESS: 50a a De,,P �
I, p-Me,'D L �� , 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 Ik to. ��fo �ai1"A rYn0 e� U�J�- OtIra Val
nee& -L
R/BLDR OR CONTRACTOR SIGNATURE
aame.S c�rv�ld �
Print Name
STATE OF FLORIDA
COUNTY OF �( Q—
DATE
ACKNOWLEDGED BEFORE ME THIS q 4'DAY OF �J 120 A
BY -7amen LSnqd WHO IS PERSONALLY KNOWN TO ME �, OR
HAS PROVIDED
STATE OF FLORIDA, County of
11 s llea®
.TURE OF NOTARY
SABRINA L. BLACK
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
AS
Example: [15 divided by 23=.65(%)] $175(permit fee) x.65=$113.75 (renewal fee)
Revised 7/21/2014
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PLANNING 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 NUMBERA M-5 r o✓ 3 ADDRESS: 50a a De,,P �
I, p-Me,'D L �� , 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 Ik to. ��fo �ai1"A rYn0 e� U�J�- OtIra Val
nee& -L
R/BLDR OR CONTRACTOR SIGNATURE
aame.S c�rv�ld �
Print Name
STATE OF FLORIDA
COUNTY OF �( Q—
DATE
ACKNOWLEDGED BEFORE ME THIS q 4'DAY OF �J 120 A
BY -7amen LSnqd WHO IS PERSONALLY KNOWN TO ME �, OR
HAS PROVIDED
STATE OF FLORIDA, County of
11 s llea®
.TURE OF NOTARY
SABRINA L. BLACK
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
AS
Example: [15 divided by 23=.65(%)] $175(permit fee) x.65=$113.75 (renewal fee)
Revised 7/21/2014
5p. ��,�$SION
#GG 289862 y
0.;ff
oa eOnded t��o �� ' a
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