HomeMy WebLinkAboutPERMIT RENEWAL REQUESTR ti M
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 467,1578
PERMIT RENEWAL REQUEST ����4��1
e
PERM1T'N(T1%MIKR: SLC 1809-0660
ADDMSS: 3042 NW Radcliffe Way
Desiree McIntosh , 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., l
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 Final Inspection still needs to be scheduled and passed
5/7/19
OR CONTRACTOR SIGNATURE
Cheyenne Ellison
Print Name
S?"AT1 OF FLORIDA
CoWNTY OF Mahan
A(,'KN()'WLEDGED BEFORE ME T'FIIS 7 DAY OF May
DATE
2019
13Y Cheyenne Ellison WHO IS 13EPSONALLY KNOWN TO ME x . OR
HAS PROVIDED
$ 'ATl3 OF FLO , county of Martin
;ICNA 0 O Y
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
AS IDENTIFICATION.
MyNotary PUb1ic Slate of Florida
Cgjn N MC1ntG 2
My Commission GG 2®9899
xpires 12/1112022.
Example., [I5 divided by 23=.65(%)1 $I75(peirmit fee) x .65=$I 13.75 (renewal fee)
Revised 7/2112014
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