HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
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PERMIT RENEWAL REQUEST
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PERMIT NUMBER: k9-0 _0 ADDRESS: —+Sros `C-V�V'VIq We i 4 PiC-rCe'
I, ,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
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OgqWNER/B//��LDR OR CONTRACTOR SIGNATURE DATE
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Print Name
STATE OF FLORI A
COUNTY OF
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ACKNOWLEDGED BEFORE ME THIS DAY OF �� 201
B WHO IS PERSONALLY KNOWN TO ME OR
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PROVIDED AS IDENTIFICATION.
F FLORID ou of a vP49 _ I•"I��H'�'II�UF` R HMING
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CC�L1M1SSK.?�7#GG 275060
FXFIF;ES:Qec m ° ,2022
Lord s e ber20
G j�N iVOiary Pubic Urge OF NOTAR SE _ rwriiers
FOR OFFICE USE ONLY:
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Number of Open Inspections:
Total Inspections: j
(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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