HomeMy WebLinkAboutPERMIT RENEWAL REQUESTMay 07 20, 01:59p
2300 VIRGINIAAI'
FORT PIERCE, FL 3-
(772) 462-1553 Fax (772) 46,20578
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PERMIT RENEWAL REQUEST
SCANNED"
StLuc[eCout*
\ PERMIT NUMBER (I 0 7 - Ud O ADDRESS: '3� s j < a 1, L C
I, •,_ IJr^c,�, l'bcv-%4— am requesting that the above permit be renewed. -I
undersY at I in st 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 ho (e 1, o .n e pro 014- 1 or.� e/ �•
E'K,OPc1ed
OWNER/ L Off— CONTRA�CTO�R SIGNATURE DATE
6r'cnc (,el3z d Oovw.-�
Print Name
STATE OF FLOIZJ /
COUNTY OF , _� I 1
\ACKNOWLEDGED BEFORE TUBS {0DAY OF 1� 20�
BY tQ 1 f1�/1dL1(1i:L GWHOIS PERSONALLYKNOWN TO W OR
14AS PROVIDED 1 L Q L AS IDENTIFICATION.
STAaE OFf FL IDA, /County Io�fn1 �n (_)�� l J���l �✓ re.��"'�
l p` % MY COMMISSION#GG254868
SIGNATURE OF NOTARY - d EXPIRES:Oclober 12.2022
aP Bondxd Thou Notary puhlicUnCenrtiters
FOR OFFICE USE ONLY:
Number of Open Inspections: _
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fec: x %open = $ Renewal fee
Example:[15divided by23=.65V/u)j$175(pemdtfee) x.65=$113.75(renewalfee)
Revmed 7121/2014