HomeMy WebLinkAboutRENEWAL REQUEST PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
� BUILDING AND CODE REGULATIONS DIVISION
UNTY
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 2003 — 02�9 ADDRESS: C4ZI6 /" ��" A
,I, &rrlC?mdO kg,�L�43 731,e- O ,am requesting that the above permit be renewed. I
understand that I mustc9chedule 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 G' L� (�� Gt D S " -7at
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OWNERBLDR OR CO TRACTOR SIGNATURE DATE
krn0AIdOf���s 7 do
Print Name
STATE OF FLORIDA
COUNTY OF Gam/
ACKNOWLEDGED BE ME THIS DAY OF I�C� � 200�/
BY "17ke,' 2 ' � WHO IS PERSONALLY KNOWN TO ME C---' OR
HAS PROVIDED / AS IDENTIFICATION.
STATE OF FLORIDA,County of..f5 •• e L4 � -
/ R1)THL;LOPEZ
MYCOIIIM6SS10H#C 29A9T1
,ASSIGN OF NOTARY SEAL z :;� peas-40MY24,2023
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) TON
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Revised 7/21/2014 L
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