HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILMUNG AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
,SGANW;�U (772)412-1113 Fax (772) 462-1578
Pl)y
PERMIT RENEWAL REQUEST
PERMITNUMBER: L2DIA - COS TIADDRESS: t4--,D Wo6&crc-s� Z�Ctye- , r-4- Re�,ec
I, Lk4i —L' am requesting that the above permit be renewed. I
understafid 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 pe�riod during the renewal'period.
Justification 0-01\+cAcr�ev rnte- w', Pe— . 4 &\- ceALL�/ S� c-K aAA- piiitA
OR CONTRACTOR SIGNATURE DATE
4�
Print Name
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME TMS I llQ0 DAY OF WIS\f 20
OR
13Y WX WHO IS PERSONALLY KNOWN TO ME
HAS PROVIDED AS IDENTIFICATION.
STATE OF FLORIDA, County of !Sl�r
SIGNATURE OF NOTARY
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(%)]
Revised 7/21/2014
LASHAHNAINGRAM
state Of Florida
Notary Public
My Comm. Expires Dec 20; 2018
SEA, CommIssion # FF 177249 ; In
I,, J'A01 Bonded 11110ugh National Notary Assn.
$17-�(permit fee) x .65=$113.75 (renewal fee)