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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISIO
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: v " 7 ADDRESS: `/ 2-Q //��i �(f /j (IT'
I, / 3 -"o , 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 Ovvn- .r"
V . y V
1�v -
OR CONTRACTOR SIGNATURE
1�* I i S 61
Print Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF
BY
HAS PROVIDED
STATE OF FLORIDA, County of
20
WHO IS PERSONALLY KNOWN TO ME , OR
AS IDENTIFICATION.
SIGNATURE OF NOTARY SEAL
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