HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUII.DING AND CODE REGULATIONS DIVISION "
2300 VIRGINIA AVE
FORT PIERCE, FL34982
(772) 462-1553 Fax (772) 462-1578 J(;HIVA►ED
BY
PERMIT RENEWAL REQUEST 4t. I ""' (; pllntl
PERMIT NUMBER: 6Z-1?�O ADDRESS: WV( fi
I, l � 6 L. L/ 1� am requesting that the above permit be renewed. I
and rstand th t 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.
OWNER/BLDRORCONTRA SIGNATURE D
R,3-, ( At.:a s u s; -,
Print Nam
STATE OF FLORID -
COUNTY OF
- ACKNOWLEDGED BEFORE ME THIS DAY OF 20 IIL
BY b LU It"O IS PERSONALLY KNOWN TO ME OR
HAS PROVIDED P Y C AS IDENTIFICATION.
STATE OF FLORIDA, County of V�fitn/
�•"J':'7$yk= AUDREY9.HUMPHREY
SI TURE OF N Y - , ' .: MY COMMISSION tl FF A. ag EXPIRES: March 6.2019
'7%F,'pt�y�•• Bonded ThN NOLry PubGe UndernEers
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(Vo)] $175(permit fee) x .654113.75 (renewal fee) FED 14 2m
Revised 7212014