HomeMy WebLinkAboutPERMIT RENEWAL REQUESTz
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
I
BUILDING AND !CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772)462-1578
SCANNM
BY
saueie C®unb,
PERMIT NUMBER: 1 0?r juoO
I, , am
understand that I must schedule and pass all requir
understand that this is a ONE TIME RENEWAL
passing inspection during any six month period du.
TOR CONTRACTOR SIGNATURE
C
Name
STATE OF FLORIDA
COUNTY OF Q:l�
ACKNOWLEDGED BEFORE ME TFUS�� DAY OF
lie -
BY r On .I.IWTI S WHO IS 1
HAS PROVIDED
STATE OF FLORIDA, County of � �'L\
SIGNATURE OF NOTARY
FOR OFFICE USE ONLY:
RENEWAL REQUEST
Testing that the above permit be renewed. I
Lspections for the permit to be finaled. Further, I
the permit shall expire should I not receive a
the renewal period.
L-SI I
DATE
20�
LLY KNOWN TO ME OR
t
NTIFICATION.
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections) !
Percentage:
Original permit fee: x % open = $ Renewal fee
SEAL
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014
ELLEN VAUGHN
State of Florida -Notary Publi
Commission # GG 270079
My Commission Expires