HomeMy WebLinkAboutrenewal formPERMIT NUMBER: 1812-0103
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
MO VIRGMIA AVE
FORS' PIERCE, FL 34992
(772) 442-1553 FIX (M) 462-1579
PERMIT RENEWAL REQUEST
ADDRESS: 10851 S Ocean Dr #72
I, WAYNE T BURNETT 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.
7ucation ISSUE SETTING A DATE FOR INSPECTION.
QR CONTRACTOR SIGNATURE
WAYNE T BURNETT
Print Name
STATE OF FLORIDA
COUNTY OF --
ACKNOWLEDGED BEFORE ME THIS 28
BY WAYNE T BURNTT
HAS PROVIDED
STATE A, ST LUCIE
SIGN NOTARY
SIGN
FOR OFFICE USE ONLY:
DAY OF MAY
5/28/2021
DATE
2021
WHO RSONALLY KNOWN TO OR
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
AS IDENTIFICATION.
NOWY Pmbk SUM Of POld.
My Cor+vnlabra 101149
EOM "normza
AAAAAAA
Example: [15 divided by 23=.65(%)] $175(pcnnit fee) z .65=5113.75 (renewal fee)
Reviwd 7/2I/2014