HomeMy WebLinkAboutPERMIT RENEWAL REQUESTrn� PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIAAVE
FORT PIERCE, FL 34962 sCANN( p
(772)462-1553 Fax (772)462-1578
St Luo� County
PERMIT RENEWAL REQUEST
PERMITNUMBER: 1901-0103 ADDRESS: 4570 S Ocean Drive Ft. Pierce FI
I Mike Flaxman 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 h L&u o1 1 u$ nl I
16 S
OWNS 13LD ONT OR SIGNATURE 'DATEI�
Prin]tNam��
STATE OF FL91{I�A
COUNTY OP (.lam
ACKNOWiEDGBDBBFOR£METHISDAYOFlIY 20
BY bjUffg� WHO IS PERSONALLY KNOWN TO MB-_, OR
HAS PROVIDED
AS IDENTIFICATION.
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STATE OF FLORIDA, Countyof Opt.1E1.tE6 NCALVE6
* � MYC06WISS04GG232646
C� `��" L�J s EI(PIRES:June27,2622
SMATURE OF NOTARY - ,, e . f BendedFwNelaN �mOrdsiadlal
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(%)) $175(permit fee) x .65=$113.75 (renewal fee)
Revised 721/2014
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