HomeMy WebLinkAboutpermit RenewalW07-'�
OUNTY
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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
PERMIT NUMBER: 2109-0779
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772 462-1553 Fax (772) 462-1578
I Shyan Wojtczak
,am
understand that I must schedule and pass all requir
understand that this is a ONE TIME RENEWAL
passing inspection during any six month period du
Justification Homeowner was out of town
OR CiSjlelTRACTOR SIGNATURE
Shyan Wojtczak
Print Name
STATE OF FLORIDA
COUNTY OF^
ACKNOWLEDGED BEFORE ME THIS `J DAY OF DC,
BY BY JQ � C.-727V,, WHO IS PERSO
HAS PROVIDED �JL
STATE OF FL RID/, C_o ty of S
Y f
SIGNATURE 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 = $
Example: [15 divided by 23=.65(%)] $175(permit fee) x
Revised 7/21/2014
RENEWAL REQUEST
4160 N Highway Al Unit 1105A
questing that the above permit be renewed. I
inspections for the permit to be finaled. Further, I
d the permit shall expire should I not receive a
g the renewal period.
12-14-21
DATE
20a �
ALLY KNOWN TO ME , OR
AS IDENTIFICATION.
�otaR Michael MontelYc
o Notary Public
SEAL 'MState of Florida
? Comm# HH0256
ws�ycE tie�� Expires 7/30/202
fee
113.75 (renewal fee)