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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
- - BUILDING AND CODE REGULATIONS DIVISION
016
2300 VIRGINIA AVE RECEIVED
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
DEC 3 0 2021
PERMIT RENEWAL REQUEST Lucie County St.
Q Permitting
PERMIT NUMBER: I C-) ADDRESS: r�JCotJ� \��(2Y T1,) Li c)&- l e ze,F L
I, 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 r �� � h C
Uh Y(1 GS M D
OWNER RLDR OR CONTRACTOR SIGNATURE DATE
Print Name
STATE OF FLORI
COUNTY OF
ACKNOWLEDGED BEFORE ME T DAY OF e� 20-6�
BY 1- r I0 IS PERSONALLY KNOWN TO ME ,OR
HAS PROVIDED (_ ��. AS IDENTIFICATION.
STATE OF FLO DA, unty o
KAREN S. NIELSEN
SIGNATURE OF NOTARY ; .;State of I-Ioridag gary Public
.* `c Commissio"S 207484
!sty Ccrnrnission Expires
June 12, 2022
m n+
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)
Revised 7/21/2014