HomeMy WebLinkAboutRenewal FormPLANNING 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: 2012-0573 ADDRESS: 1160 Nettles Blvd
I Douglas Roe , 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.
Justification
✓ e l 2 A ZZ
OWNERBLDR OR CONTRACTOR SIGNATURE DATE
DnulleLs C. /?oe-
Print Nade
STATE OF FLORIDA
COUNTY OF /`IA✓f�ti
ACKNOWLEDGED BEFORE ME THIS DAY OF �� ���o _�P� 20 7-1
BY 1 p� 4fi �•oa° WHO IS PERSONALLY KNOWN TO ME, OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, County of
SIG RE OF NOTARY
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
E�t==]
Stew of FWda
hhSion HH 1559763/2025
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014