HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPART
BUILDING AND CODE REGULATIONS DIVISI
u ,: i300 VIRGINIA AVE �01 � ((�
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578 �� f�
�q'o �Q
PERMIT RENEWAL REQUEST
PERMIT NUMBERS t L r f 76 41-G ti q ADDRESS:5(I 1 5
I, S� ;_,1 S ,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 1 R MCLu 1P cc) aliv SS
CA
r
OWNEPUBL R OR CONT CTOR SIGNATURE DAT
Print Wme
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED
/BEFORE ME THIS / DAY OF ! I 20 If
BY L)9 l'� V��a 1f 0f) 91 r,05• WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED/4-�/20 -�./3`(2 _ r OtI K! /)6I'ler C1(e*AS IDENTIFICATION.
STATE OF FLORIDA,County of -5 • C/r- ' NUBIA E DIAZ
'� Qz I'll MY COMMISSION#GG 133090
SIGNATURE OF NOTARY SEAL ''�'t!; EXPIRES August 09,2021
FOR OFFICE USE ONLY: �¢
Number of Open.Inspections: �6
Total Inspections: 1a
(Divide open by total to get%of open inspections)
Percentage: %G1 -
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