HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
•
BUILDING AND CODE REGULATIONS DIVISION
UNTY
2300 VMGINIA AVE
FORT PIERCE, FL 34982
SCANNED (772);462-1553 Fax (772) 462-1578
BY
St LUCie Coanfy PERMIT RENEWAL REQUEST
PERMIT NUMBER: (� �/ �ADDRESS:
I
I, , 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 Kl?rn r m A l,A)1�V l rJd !9 Ll%<
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OWNERBLDR OR CONTRACTOR SIGNATURE I DATE
Print Name Tr I
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS C23.--DAY OF 204
BY /// • WHO IS P ONALLY KNOWN TO ME OR
HAS PROVIDED - o r tr, AS IDENTIFICATION.
STA F FLORIDA, County of
6&dAiw 4f
SIGNATURE OF NOYARY
FOR OFFICE USE ONLY:
SEAL
v
Number of Open Inspections: r p AUDREY B. HUMPHREY
Total Inspections: MY COMMISSION#.FF174772
EXPIRES: March 6, 2019
(Divide open by total to get % of open inspections) Public uaaerwrllers
Percentage: "^;F••F�ge•' BoededThruNotary
Original permit fee: x % open = $ Renewal fee
Example: [15 divided by 23=.65(%)] $175(permit fee) is .65=$113.75 (renewal fee)
Revised 7/21/2014