HomeMy WebLinkAboutRenewal Request 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 RENEWALREQUEST
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PERMIT NUMnnBER: .I.! -f O-1�W1L>t0 ADDRESS:
I, �Ul�ft.' f� �un��,P ,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 f
passing inspection during any six month period during the renewal period. / -
Justification- We t;- fff, WOCLUM L��I+� A i pX1W.�1oolZ.1� on a wee '�.e R
OWNERIBLDR OR CO RAC R SIGNATURE DATE
Print Name
STATE OF FLORIDA,
COUNTY OF -7
ACKNOWLEDGED BEFORE ME TffiS_ DAY OF [_ ,P m f;r ,20 G•0
BY RobeA Ltki �C! WHO IS PERSONALLY KNOWN TO ME OR �
HAS PROVIDED AS IDENTIFICATION.
STATE F FLORIDA,County of jn,,),i�� M r
. due LAUR1EgCH,30WELL
SIGNATURE OF NOTARY SEAL *o�,•• Comrn6sloniE60348949
Ayr f o� Expires March 10,2023
' � `cOff�� Bnnded7fiNBudgetNotarySen:
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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