HomeMy WebLinkAboutPermit Renewal 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 NUMBER:
� G C>Z,GZ ADDRESS: Z3 0 Z-
1, ?011 —3' V.,- V), ,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
O D R'CONTRACTOR SIGNATURE DATE
��'j Zj�"'VJ. Cw�
Print Name
STATE OF FLORIDA
COUNTY OF- f5l:
ACKNOWLEDGED BEFORE ME THIS I DAY OF �� 1�. 20 '✓ 0=a-CO `-N
� `m aN
BY WHO IS PERSONALLY KNOWN TO ME ,OR CCc0"'N
=)
oC7 c
y p cp
HAS PROVIDED L AS IDENTIFICATION. w .N
o m
wo.- E
=LL N 0
STATE OF FLORIDA,County of �— Lg a-e- Q o E U
wmE ?
2 �L)
SIG A RE 0 N Y SEAL �;ltttt,,
�cb o�
71t11
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