HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
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IV. = ' - - BUILDING AND CODE REGULATIONS DIVISION
• 2300 VIRGINIA AVE
•MM OWN FORT PIERCE, FL 34982 ��E1
(772)462-1553 Fax (772)462-1578 BY
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PERMIT RENEWAL REQUEST
PERMIT NUMBER: 11()1 • 0 -1 LI ADDRESS: RD 1 1'5 0 n t-y- w-5 0 o
I, V lr1cP - YY1 r� 1i d , 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,
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 oee & m o (--e -1-n -e �0 s f
C DATE
OWNER/BLDR OR CONTRACTOR SIGNATURE
Print Name
STATE OF FLO
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF
20� -
BY WHO IS PERSONALLY KNOWN TO .Ok
AS IDENTIFICATION.
HAS PROVIDED
SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections: '0 r ;F� IASHAHNAINGRAM-RAHMING
(Divide open b total to get % of open inspections) I
,Y 4 *: MY COMMISSION # GG 275060
Percentage: (J EXPIRES: Decembeft 2022
Original permit fee: • Ou x % open = $ �s Renewal e .... F`oP Bonded Thru Notary Public Underwriters
L—"
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113. r renewa ee
Revised 7/21/2014