HomeMy WebLinkAbout0911-0038 PERMIT RENEWAL REQUESTPLANNING AND
ADDRESS: %OM69 v' .
I, /79
RENEWED FOR 18 MONTHS. I 1
REQUIRED INSPECTIONS FOR I
THIS IS A ONE TIME RENEWAL
PASSING INSPECTION DURING
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scAN ED
VELOPMENT SERVICES DEPARTMENT BY
and Code Regulations Division S$ Lude C011ntl
2300 VIRGINIA AVE.
FORT PIERCE, FL 34982
(772)462-1553
4IT RENEWAL REQUEST
FILE -C%Ajftr=5'kY
P P- . PERMIT NUMBER: n 9111 — (n 038
"T-S , AM REQUESTING THAT THE ABOVE PERMIT IS
ERSTAND THAT I MUST SCHEDULE AND PASS ALL
PERMIT TO BE FINALED. FURTHER, I UNDERSTAND THAT
) THE PERMIT SHALL EXPIRE SHOULD I NOT RECEIVE A
'SIX MONTHS PERIOD DURING THE RENEWAL PERIOD.
f c /f
WN LDR OR CONTRACTOR SIGN ' TURE DATE
STATE OF FLORIDA, County of //��,, O
ACKNOWLEDGED BEFORE ME THIS (
DAY OF � er , 20l I
BY 1 a �ob� WHO IS ONALL KNOWN TO ME , OR
HAS PROVIDED AS IDENTIFICATION.
7r-P711
County of
SIGNA F OTAR
FOR OFFICE USE ONLY:
RENEWAL FEE: $
No. of Open Inspections —
SEAL
ANNE CZERWINSKI
COMMISSIO MY COMMISSION # DD 889657
o EXPIRES: May 14 2013
%fJf th` Bonded Thru Notary ('ubi'ic Underwriters
(% of Open Inspections).
Original Permit Fee $ x Open Inspections (%) = $ (Renewal Fee).
Example: [15 = 23 = .65(%)] $ 75.00(permit fee) x .65(%) = $113.75 (Renewal Fee)
SLCPDSD REV 4/11/2011
No. of Inspections
pc��oe�
�
OCT 13 2011 D