HomeMy WebLinkAboutrenewal request with current product approvalACKNOWLEDGED BEFORE ME THIS
BY
HAS PROVIDED
STATE OFF RIDA, Coun of
2
SIGNATURE OF NO ARY
FOR OFFICE USE ONLY:
CO U NT
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34992
(772)462-1553 Fax (772) 462.1578
PERMIT RENEWAL REQUEST
PERMITNUMBER: ae'09— ay80 ADDRESS:S,�/d J7inC�rep Dr•
)I, r i c? n 1�1 a�pgg�am requesting that the above permit be renewed. I
understand that I must schedule ndh pass all required inspections for the permit to be finaled. Further
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 Ke —
OWNER/BLEIO C OR SIGNATURE
Sr/ctn Aa /dn uJ
Print Name
Ir
DATE
N
Victor G Alterizlo
Notary Public, State of Florida
STATE OF FLORIDA My Commission Expires 11/05/2022
COUNTY OF �T'�l�PiLB Commission No. GG 274292
�2 DAY OF ��� .20
WHO IS PERSONALLY KNOWN TO ME OR
Number of Open Inspections:
Total Inspections:
(Divide open by total to get 0/u of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
AS IDENTIFICATION.
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 72112014
Victor G A"
Notary Public, S4 1.i;•.1
My Commission E>
Commission 1`I