HomeMy WebLinkAboutPermit Renewal RequestPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
® BUILDING AND CODE REGULATIONS DIVISION
fl , 2300 VIRGINIA AVE
`~ FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 1 �G ` 7 ADDRESS: kid' (�1
I, , 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
XWRER—J�BLDR
OR CONTRACTOR SIGNATURE
N& 74-;e4w
Print Name
STATE OF FL O A
COUNTY OF `
ACKNOWLEDGED BEFORE ME THIS J
BY
HAS PROVIDED
DATE
DAY O , 20 ) /
WHO IS PERSONALLY KNOWN TO MEOR
AS IDENTIFICATION.
STA OF FLORIDA, C my of r o "ry public state of Florida
Frances Donza
,per My Commission GG 092440
of
SIGNATURE OF NOTARY F�6+ Expires 07/27/2021
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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