HomeMy WebLinkAboutPERMIT RENEWAL REQUESTBY
St Lucie Cou*
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMITNUMBER: SLC1801-0466
PERMIT RENEWAL REQUEST
ADDRESS: 5004 La Salle St, Fort Pierce, FL 34951
I,Q Z �.S %�� Art n .r ,.r; , 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 >LI C-d-r-J94o (2x-s-cf>i9u a&i 2b14)N�E& ` ur"4
OWNER/BLDR OR CONTRACTOR SIGNATURE
onminick P-eloS+in0
Print Name
12 'L ) S
DATE
STATE OF FLORIDA
COUNTY OF Pal vn 13f ac,h
ACKNOWLEDGED BEFORE ME THIS Z7 DAY OF �c�e_e rn h� r , 20_L-r'
BY WHO IS PERSONALLY KNOWN TOME , OR
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, Cgunty of
�,►� �+a Notary Public State of Florida
SI ATURE OF �T SEAL �^ MyiComm Commission GG 232581
Edwards
Expires 10/22/2022
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