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:: 1/D ADDRESS:, z90 ti ^d am
1, .2)e'�is It— Si�rii 7L� ,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-WNER/BLDR OR CONTRACTOR SIGNATURE / DATE
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Print Name S,57 36
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS�DAY OF %� 20 '020'
BY WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA,County of �T' 2,ue-�
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SIG ATURE OF NOTARY SEAL L L Z£8 t3 uoiss. o�AIN
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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
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