HomeMy WebLinkAboutPermit Renewal Request PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: �U ��� ADDRESS:
I, ,4► o' e s5" ,am requesting that the above permit be renewed. I
understand that rmist sc edule 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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OWNER/B DR OR CONTRACTOR SIGNATURE I5ATE
4'�;t'je'z'k-
Print Name
STATE OF FLORID
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF ��'-�T 20
BY POV PO 2 WHO IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED AS IDENTIFICATION
AUDREY B.HUMPHREY
STATE OF FLO ounty f Off/ 1. ' f✓VWl `�PY��m�
=a° MY COMMISSION!#GG 300817
* * EXPIRES:March 6,202 3
PubGeUnderwriters
Bonded ThN Notafy ,�z�„aaY:L
SIGN RE OF NO Y � ..
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
Example: [15 divided by 23=.65(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7/21/2014