HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTI►ZENT
BUILDING AND CODE REGULATIONS DIVISION
2388 \TRGIN7A AVE
FORT PIERCE, FL 34982
.(772)462-1553 Fax (772)462-1578
PERMIT RENEWAL REQUEST
oGANNED
BY
PERRMIIT'Nir;%AW rr7� D J/v ADDRESS: c�d �
f, �.•i1a-�` —p^" %� OS r`'ti , 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
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OWNER/BLDR OR CONTRACTOR SIGNATUREd
Print Name
t�d�4 CAaA IAA
STATE OF Pi,9i2tBA-
COUNTY OF ILkL e, Nl` IL
d 3 Z) a?
DA
ACKNOWLEDGED BEFORE ME THIS � DAY OF Kul
2l1
BYQ�(•ec �9Stl�'l
y � //}} 1 WHO IS PERSONALLY KNOWN TOME OR
HASPROVIDED L�7 Vim. l2�'j22- AS IDENTIFICATION.
N°�'- CA&4"LA- oatnnnn„rro
S7'ATR OF Ia-'iaaan�r,.....«. I k 0, \ N(� 'CLA a Je /)is ry .
SIG A UR FNO AR ?' No
9
FOR OFFICE USE ONLY:
'� COUCf�,`•
Number of Open Inspections: _
w'uaz .mn•'"
Total Inspections:
(Divide open by total to get %of open inspections)
Percentage:
Original permit 'fee: x "/o open = S Renewal fee
Example: [15 divided by 23=.65C/,)] $175(permit fee) x .65=S113.75 (renewal fee)
Re iud 7121/2014
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