HomeMy WebLinkAbout0911-0038 PERMIT RENEWAL REQUEST 2-10-11h
&NNING & DE
BUILDING &
F(
LOPMENT SERVICES DEPARTMENT
'dDE REGULATIONS DIVISION
00 VIRGINIA-AVE: -
I�(772)462-4553
PIERCE, FL 34982
..
BY
st Lucie cOU1
1t! PERMIT NEWAL REQUEST
- ADDRESS: / 1 , C,w s, �o ,, �J PERMIT NUMBER: ' 00
I, %%/� /��,1 ;(�D(?�LS , AM REQUESTING THAT THE ABOVE PERMIT IS
RENEWED FOR 18 MONTHS. 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 MONTHS PERIOD DURING THE RENEWAL PERIOD.
—F-r sb I
SIGNATURE DATE
STATE OF FL04MA ,
COUNTY OF
SWORN TO AND ACKNOWLEDGED BE
BY f ICh,�2e ( Q
HAS PROVIDED
N04Ex PfiIt 1C, STATE OF FLORIDA
ARY
FOR OFFICE USE ONLY:
RENEWAL FEE:
OPEN INSPECTIONS (_) X PERMIT
TOTAL INSPECTIONS:
SLCPDSD REV S/5/2010
E ME THIS DAY OF `� ( . 20 I
WHO IS P ALLY N TO ME _ . OR
AS IDENTIFICATION.
:2�a +" `�',.
ANNECZERNNSI �
4. y: - = .: .=
MY COMMISSION # DD 869657
COMIIIISSI
EXPIRES: May 14, 2013
p,'t h'NS'
onded Thru Notary Public Underwriters
(RENEWAL FEE)