HomeMy WebLinkAboutPermit Renewal RequestPLANNING 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: / 1 / )- U� 0 ADDRESS: ` to I6f O PlAl/.' nt/i/r brj/Z ri 1-r Pil-'/2dN
I, t"-tw"1 , 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
4te4j��,
WW4LE BL R OR CONTRACTOR SIGNATURE
IFQe1�
Print Name
DATE
STATE OF FLORID j
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS C:U DAY OF au 120 �7
BY [ 1 �' Imo' WHO IS PERSONALLY KNOWN TO ME �, OR
HAS PROVIDED
STATE OF FLORIDA, County of
TURE OF NOjtARY
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
AS IDENTIFICATION.
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal
Revised 7/21/2014
A- U E g HUMPHREY
MY COMMISSION # Go 300817
EXPIRES: March 6, 2023
gonded'mru Notary
Public Undetw0tels
AUG 2 2 2019
n-rmitting Department
St. Lucie County, FL