HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
-- IIi1 FORT PIERCE, FL 34952
(772)462-1553 Fax (772) 462-1578
SCANNED PERMIT RENEWAL REQUEST
BY
St. Lucie County Q 1
PERMIT NUMBER: 1170,E _O 290 ADDRESS: l Q l ( D S �C�Pr/�+ :1�12-
I,Li� ,'t07 , am requesting that the above permit be renewed. I
understand that ust 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 F—Y1- &%ev2 n r Ue . -5-e"n d -1��
OWNER/BLDR OYeCONTRAWDR SIGNATURE
:D2 L"" !
Print Name
STATE OF FLORID.4,
COUNTY OF �L�,$`
DATE
ACKNOWLEDGED BEFORE ME THIS � DAY OF V' -b 201
BY Mist, l WHO IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED AS AS IDENTIFICATION.
:YIS�TE OF FLORIDA,
C mty of S�•^�C,.SL
\_MN TORE OF NOTARY SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections: _
(Divide open by total to get % of open inspections) oo<^�s;•., LASHAHNA INGRAM
+ . �- Notary Public - State of Florida
Percentage_ ' . . My Comm. Expires Dec 20, 2018
Original permit fee: x %open = $ Renewal fee 9, 'o;' Commission e FF c 20, 2
Bonded throw hNational Not,r Acn
Example: i15divided by23=.65(%)]$175(permitfee) x.65=$113.75(renewal•fee)�;� �9 p_r
Revised 7212014