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: /¢ ADDRESS: ,-31.92 16Z Y1ID1v !Y J?ja
I, ZC-RQ-y EA/tV E-Tr jP-, ,am requesting that the above permit be renewed. I
understand that I must schedule 6nd 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 RB OR CONTRACTOPXGNATURE DATE
_LE-,Rny J 3k&iAI6T7- Icre-
Print Name
STATE OF FLORIDA1
COUNTY OF j-1— J—!t.Y ,
ACKNOWLEDGED BEFORE ME THIS ] DAY OF 20
BY WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of
SIGNATURE OF NOTARY SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get /o of open inspections) �;° �`�=Sta a AVER B URF
Percentage: y ., �o of Florida-Not ORD
Original permit fee: x%open = $ Renewal fee '%?�� ,:�� 17
My Cossion #CO 18 Public
February Expires
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee) �6, 2022
Revised 7/21/2014