HomeMy WebLinkAboutPERMIT RENEWAL REQUESTCC1
F L, C' A
St
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
SCANNED
BY
Lucie counts,
PERMIT RENEWAL REQUEST
PERMIT NUMBER: S UDDRESS: L? S -S 0 �J t/ 241")—
I, DArr1rJ t( CwL. N&-12So 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 Knot receive a
passing inspection during any six month period during the renewal period.
Justification EXIP a 2 1 P2Q K,—lrbvA
O `ER/BL _ G T[LA OR SIGNATURE
Rjj wL ah8
Print Name
�.7t�/ 17
DAT
STATE OF
FLORIDA,
COUM'Y Of: �// ACKNOWLEDGED BE ORE ME THIS .ZL/- DAY OF -� 20 Xf
B�./ WHO IS ERSONALLY O hffi OR
HAS PROV[D D AS IDENTIFICATION.
SI'ATE'O(F FLORIDA, u/n[
//��
SIGN T RE OF NOTAR --��
FOR OFFICE USE ONLY:
Number of
Open Inspections: _ /� v ' 0 V'
Total Inspections:
(Divide open. by total to get % of open inspections)
Percentage: ° Renewal
JANE L. CONNEfl
Notary Pu011C - Strict of Florida
Corgmisslon I GO 036070
My Comm. Expires Doc 10, 2020
Banded through National Notary Asap.
Example: [l$ divided by 23=.65(%)] 5173(permit fee) x.65m$I13.75 (renewal fee)
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