HomeMy WebLinkAboutPERMIT RENEWAL REQUESTFrom: Mike Helseenberg Fan: 27728710990 To: Fax: (772) 462.2578 Page: 2 of 3 2012812029 4:07 PM
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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINLi,AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462.1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: U�+ / /W ADDRESS; Q['[)(;o A- W, y,� h . f� l
I, M) �' ' am requesting that the above permit be renewed. I
understand that I must schedule an ass 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
OWNER/BLDR
Print Name
STATE OF FL D . p
COUNTY Or �'
DATE
ACKNOWLEDGED BEFORE METHIS _t-919 : DAY OF ,. /� . 20I 9q
BY _. .—WHOISPERSONALLYKNOWNTOME OR
HAS PROVIDED
T TF OF FLORIDA, County of
f
SIGNATURE OFF NOTARY
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get a/e of open inspections)
Pewentage:
Original permit fee: x"n open = S Renewal fee
AS IDENTIFICATION.
,IkRY Shanon O'Shea
NOTARY PUBLIC
STATE OF FLORIDA
SEAIJ z COMM# G(3258038
Expires 911212022
- --- —Example:—[-!3_divided-by-27�:G5(%)]-$175(permirfee)x-6S=5113.75 renowaffec)
Revised 71I2014