HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982-LANNE®
(772) 462-1553 Fax (772) 462-1578 BY
PERMIT RENEWAL REQUEST ""e County
PERMIT NUMBER: &5 (Ja.^ Q 3 -ADDRESS: - ,:?90 IV, AtR Fr p!mci
I, d; , 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
OR
Ali S40 rr- ,(fowl 5
Print Name
q-45�-i 7
DATE
STATE OF FLORIDA
COUNTY of ?GAlrn RcGC.FI
ACKNOWLEDGED BEFORE ME THIS = DAY OF , 20 - I�
EY _N'01 -4KOO Lewis WHO IS PERSONALLY KNOWN TO ME 'r, OR
HAS PROVIDED 'R- D-Q aSI I`b AS IDENTIFICATION.
STATE OF FLORIPA, County of QAl rrl kc� CS-1
SIGNATURZj0 NOTARY SEAL
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 7/212014
tlJt NUBIA BROWN
NOTARY PUBLIC
n STATE OF FLORIDA
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'�4CCE 1 �0 Expires 6/16/2021