HomeMy WebLinkAboutRenewal RequestPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-15 78
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 2005-0465 ADDRESS: 4911 Bald Cypress Trail, Fort Pierce, FL 34951
I Jay David Silver , 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 EWI;LM OR CONTRACTOR SIGNATURE DATE
Jay David Silver
Print Name
STATE OF FLORIDA
COUNTY OF Hibb.,.gh C/
ACKNOWLEDGED BEFORE ME THIS b DAY OF ', 220,D-1
BY Jay David Silver WHO IS PERSONALLY KNOA TO ME ✓ A , OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, County
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
10'q oy°.,. JOY BENEOETTI
¢'N, Notary Public - State of Florida
y?' Commission 9 GG 195511
SEAL ��'or M1"sMy Comm. Expires Apr 6,2022
Bonded through National Notary Assn.
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014