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 W - o.� 19 ADDRESS: !q l®o '6 r_y�L
I, \ram ,, 44hh , 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 Wei 1�1 t4A .�� S�F�,�/D/t✓
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O R/BLDR OR CONTRACTOR SIGNATURE
Print Name
STATE OF FLORIDA
COUNTY OF 2-- U-k CA �-
ACKNOWLEDGED BEFORE ME THIS
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BY 1 0-kAK 1C Cat. h r)
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DATT
_�� DAY OF 1) �'>-<-' - 20 (0'
WHO IS PERSONALLY KNOWN TO ME , OR
HAS PROVIDED E b b L— AS IDENTIFICATION.
STATE OF FLORIDA, County of ��' (e l 'e-- 5y pU� E L L E N VA U G H N
?a? 6' State of Florida -Notary Public
®Q= Commission # GG 270079
SIGNATURE OF NOTARY U SEAL �i�FF��Qo� My Commission Expires
'nnrn�` October 22 2022
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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