HomeMy WebLinkAboutPERMIT RENEAL REQUESTqc c—(3k4 C
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT - -
•
o BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578 g fl S b b 3 q �
PERMIT RENEWAL REQUEST
r,
n 1 a SCANNED
St PERMIT NUMBER: IGUI -6y'3g ADDRESS: � U 7-: sera(( J WC— ' � LIcB cool ty
I, Q cm P CO.A L)f— ( ( , 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.
JustificationFWMV,
�
0 O LDR OR CONTRACTOR SIGNATURE
Doke, 6wdell
Print Name
/a --a - iq
DATE
STATE OF FL D
COUNTY OF /� ,., ��/� G
ACKN`/O�,WLE\D/GED BEFORE pM T I IS -V L L DAY OF (,]'�'�k' ja—r 20 I I
BY 6Iu u a Aoej ` WHO IS PERSONALLY KNOWN TOME ki , OR
HAS PROVIDED
AS IDENTIFICATION.
STATE OF FLORIDA, County of 5+1 A )� A,�, ; .,, pANIELLE GCNCALVES
O �!8'••44t,
'� p(PIRES:June27,2022
SIGNATURE OF NOTARY ."•`', BondedlTmNalatl Wbia Uade�wdtars
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(0/o)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014