HomeMy WebLinkAboutPERMIT RENEWAL AFFIDAVPLANNING 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: S�—C (O� - 06o(6 ADDREss: Jl3 NW wwrleCs cRE,EK
1, A r-INuK 6Ar64�c M Iu A , am requesting that the above permit be renewed. I
understand that I must schedule and pass all required inspections for the permit to be fmaled. 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
OWNER/BLDR OR CONTRACTOR SIGNATURE
AgTgJr- 6VCCCA1%AN4)
Print Name
STATE OF FLORIDA
COUNTY OF SAIA % 4 UC i.
a 40=g
DATE
ACKNOWLEDGED BEFORE ME THIS D DAY OF $ e b r u a+' , 20/221
BY A-,r" lu V �► (�G l m a A N WHO IS PERSONALLY KNOWN TO ME ✓ OR
HAS PROVIDED
AS IDENTIFICATION.
STY OF FLORIDA County of UA (J;SPY•' ~. JESSICASANCHEZ
commission # HH 081950
Expires January 19, 2025
(7RE OF NODSEA[ ....... Bonded Thin Troy Fain Insurance 8004854M
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(0/o)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014