HomeMy WebLinkAboutPermit 2102-0326 RenewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
00 VIRGINIA AVE
FORT PIERCE., FL 34982
(772) 462-1 S53 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: ?K1 � � " � c��j ADDRESS
r
t
I, LA n Ct4 r1. , 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,
understand that this is a ENE TIME RENEWAL and the permit shall expire should I not receive a
passing inspection during any six month period during the renewal period.
Justification Oel C�� _ � �1 d�C��ri �i �:� ��U��• bik' -4)
I
OWNER7BLDR 0
if
Print Name
i
CONTRACTOR
CC, -4r�4
f Z /3/z.-&r t, r
SIG ATURE DATE
STATE OF FLORIDA
COUNTYF
ACKNOWLEDGED BEFORE ME THIS DAY OF
BY
HAS PROVIDED
STATE OF,�LoRIDA, County of
SIGNATURE F -TAR
W=406=IEW4nd m=M 4RMEELM MMM Wi�idhM�a M�� M M M M Mai
FOR OFFICE USE ONLY:
zo '7--, (
f
WHO IS PERSONALLY 7 VwN TO ME OR
AS IDENTIFICATION,
Number of Open Inspections:
Total Inspections;
(D i id e op en b y total to get % o f op en i n spections)
Percentages - - - -
Original permit fee-. x%open $
Renewal fee
Example: [15 divided by 23=.65(°l0)] $175(permit fee) x ,GS—$1 13.75 (renewal fee)
Revised 7 / 1 /2 14
0
DEBORAH II E LIC)
Notary Pubtic - Statc of Florida
ommi-s5ion 914343
MY Commi Expires Sep 18, 2023
I
a