HomeMy WebLinkAboutPermit renewal requestPLANNING AND DE v`ELOPMENT SERVICES DEPARTMENT
'�- ..,.:,' . i,:.;;- .,,.,, > BUILDING AND CODE REGULATIONS DIVISION
•
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 2003-0266 ADDRESS: 4920 Christensen Rd.
I, Chrystal Washburn , 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 Need to finish construction and schedule inspections.
OW'NL BLDR OR CONTRACTOR SIGNATURE
Chrystal Washburn
Print Name
STATE OF FLORIDA
COUNTY OF S+. L W u
4/20/21
DATE
ACKNOWLEDGED BEFORE A
ORE ME THIS ZO DAY OF e/'-a ( 20 2-(
BY l h/S 06QS1V6V-'K WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, 5.ounty of sf C.I �—
J�
SIGNifTURE OF NOT; RY
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections)
Perccutage:
Original permit fee: x % open = S Renewal fee
,oi ALEXAKRATT
:? • Notary Public - State of Florida
• P" Commission # GG 984139
SF.A1., 'oFr,d!• My Comm. Expires May 4, 2024
Bonded through National Notary Assn.
Example: [ 15 divided by 23=.65(%)] S 175(permit fee) x .65=$113.75 (renewal fee)
Revised 7 212014