HomeMy WebLinkAboutPERMIT RENEWAL REQUESTJun 2619 06:02p FL Free Will Baptists 772-567-2338 p.1
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PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
S " t BUILDING AND CODE REGULATIONS DIVISION
•
- 2300 vutcnvrAAVE
FORT PIERCE, FL34982 RECEIVED
(772) 462-1553 Fax (772) 462-1 8
SCANNED
BY
,t. Lucie County
PERMIT NUMBER: o5
JUN 2 6 2019
PERMIT RENEWAL RE T
Lucie County, Permitting
ADDRESS: W551 54. Luct 4. 61 J
I, fflj."a , E- , 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
a1 NLDR OR CONTRACTOR SIGNATURE
/V) A-1216M 6-, Rg l!� Zr?-
Print Name
STATE OF FLORIDA -
COUNTY OF j-NA ,eun IM A/
11
la �� -2ofa
DATE
ACKNOWLEDGED BEFORE ME THIS - � DAY OF i /ln E 120 1 ci
BY . &&c-Iz.✓ WI30 LS PERSONALLY KNI OWN TO ME \11/ OR
HAS PROVIDED
STATE OF FLORIDA, County of
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
AS IDENTIFICATION.
"1UA Notary
'atfEapaesPQa4(Do926ma of Flmda
P3flfi9aChristophe
SEAL
Example: (15 divided by 23=.65(%)] S175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21/2014
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Notary Pu6h at Florida "
Christopher P Flood
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