HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELQPMtn SERVICES DEPARTMENT
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1 BUILDLNG AND CODE REGULATIQNS DIV7Lude
2300"VIRGIN AAVE EIVEDFORT MERLE,FL 34982
772)462-1553• F,ax(772)'A62 1578 �� 2Q21
PERi�'IIT"RENEWAL RI+rQUEST' nty, permitting
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P.ERMIT_NUMBER ( G 7 ADDRESS: j SI y, ._ f �PC{I't !' (J`0
f? /cad l ���c��3IZ
requesting that the above permit be renew..ed I
understand"that Lmust.schedule;and pass all equtre'd inspccttons''for the pertiiitao be.finaied: Further,.I
understand that this is a.ONE TINtE.RENEWAL and the peri rt.shall expire should I"not"receiue a
passing inspection during anysix month period during the:renewal period
Justification. /I eed 5 �'��i% " o ate A. ��o":�? .•�I :t'r�'P
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OW.: R.BLDR;ORGONT. CTOR"SIGNATURE, ATE` '
Print 1 nlc
STATE OF 6�f C t;}.1a GT I ,:,Q
COUNTY QF._'fCyirLtPy .
ACKI�TOwLEDGED:BEFORE MET HIS `Z�' DAY OF � �j�}�}� ;20 `Zy :. .
BY Wll E '�1� L }-S`Z 4�1vG.101sS�wrlo IS PERSONALLY-IC��tOW\`TO ME ,OR
HAS PROVIDED FLj2\V�(L L1C F�SC AS IDEVTIFICATIO�I. 'r
�m
STATE OF�FLORIDA,gpuntyof .ciT. L 1 (tc ""
Brittany Burnett
SI NATURE.:OF NOT.4
Notary Public of,Connoutn
._ Commission Expires May 3 ;2022'
FOR OFFICE USE ONLY::
Nurnber:of Open.inspections::
Total inspections
(Diuide"open;6y rota_1;-to get O.q of open inspections)
P".ercentage:.:
Original permit fee x%open '_ $; Renewal.fee
Example: [15 divined by 23 65("/0)� SJ75(pecmit.fee)x:65=5113:75.'(renewal fee)
R&tsed 7/21-12014