HomeMy WebLinkAbout25 Bergeron Permit renewal form - signedState of Florida Department of Economic Opportunity Rebuild Florida Program Permit / HR 1463
PLANNING 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: SLC 2012-0234 ADDRESS: 607 Brack Rd Ft Pierce, FL 34982
I James W Foster , 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 During prep for work, we uncovered heavy termite damage and are forced by the terms of our contract
with the Rebuild Florida Program to conduct a structural assessment of the property for evaluation. This process is
an -going- and will take until at least the end of February to complete as we have to use a specific evaluation procedure.
<;�;qZj4o- 1/14/2022
OWNS DR OR ONTRACTOR SIGNATURE DATE
James W Foster
Print Name
STATE OF FLORIDA
COUNTY OF Okaloosa
ACKNOWLEDGED BEFORE ME THIS 14th DAY OF January
BY James Foster
HAS PROVIDED
STAkTE OF FLORIDA, County of
SIGNATURE OF NOTARY
-----------------------------------
FOR OFFICE USE ONLY:
20 22
WHO IS PERSONALLY KNOWN TO ME X , OR
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
AS IDENTIFICATION.
CAROL A PORTAL
kvt.1�' Notary Public - State of Florida
Commission # GG 339233
�= My Comm. Expires 05-28-2023
Bonded Through
RLllnsurance
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014