HomeMy WebLinkAboutPermit Renewal Request 6-3-19PLANNING 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 NUMBER17// --og '9? ADDRESS: O (y
I,� /Q/( QQ , am requesting that the above permit be renewed. I
understand that I mutt schedule and pass all required inspections for the permit to be fmaled. 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
A/ 5�'�
WNER/BLDR OR CONTRACTOR SIGNATURE
- &0) :
6�
P 'nt Name
R �c�
DATE
STATE OF FLORI, '
COUNTY OF
AC WLEDGED BEFORE ME THIS DAY OFC , 20
BY WHO IS PER 0NALLY KNOWN TO ME OR
HAS PROVIDED
AS IDENTIFICATION.
STATE F FLORIDA, CoulAyof
o00 PO& Notary Public State of Florida
Ic
SIGNA OF NOTARY r 4; Frances Donza
�
My lSiission GG 092440
�88n„ Expires07/27/2021
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