HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE -REGULATIONS -DIVISION
2300 VIRGINIA AVE
_.._ - .. FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578 SCANNED
PERMH RENEWAL REQUEST BY
St. LUCIB (;rn tnt'
PERMIT NUMBER: G —7 L ADDRESS: t" I'V `
1, v o.g 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 Off period during the renewal period.
2
LDR OR CONTRAC f�OR SIU`I�A. A E
e'Rb ti F'—'0t4f='.('U1j9 u sk
Print Nalhe
STATE OF FLORIDA 1, „ „ , i
COUNTY OF vK�"-�
��.....
ACKNOWLEDGED BEFORE METIES DAY OF
?,
BY (`3 LX I O IS PERSONALLY KNOWN TOME OR m "
HAS PROM ED i AS IDENTIFICATION. �o
2 MIS
STATE Or FLORIDA, County of �" m
wzx
s O1�'is
SIGNATURE OF NOT Y SEAL
'a
FOR OFFICE USE ONLY:
Number of Open Inspections:r
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
Example: 115 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/212014 - - I'EH Y
P018