HomeMy WebLinkAboutPermit Renewal RequestPERMIT NUMBER:
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 4624553. Fax (772) 462-1578
PERMIT RENEWAL REQUEST
ADDRESS: q g0� S.rl� a� ►2��e,r 1��,J2
I, ov�c, dt 1� c� �e�.rn , 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
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OWNER/BLDR OR CONTRACTOR SIGNATURE
Print Name
D TE
STATE OF FLORIDA O G'
COUNTY OF Y
ACKNOWLEDGED BEFORE ME THIS -DAY OF �/Y) 20
B WHO IS PE ONALLY KNOWN TO ME , OR
HAS PROVIDED R /vGr ' ,P. i _ AS IDENTIFICATION.
STATE VFVLORIDA, CCunty of
SIGNATURE OF NOT
SEAL
FOR OFFICE USE ONLY:
AUDREY B. HUMPHREY
Number of Open Inspections: :; MY COMMISSION # FF V4772
Total Ins ections: , EXPIRES: March 6.2019
p '�',••.• o? BondedThruNotaryPuhGcUnderwrxriters
(Divide open by total to get % of open inspections)
Percentage: a
Original permit fee: x % open = $ (o renewal fee
Example: [15 divided by 23=.65(%)] .$175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014