HomeMy WebLinkAboutSUBMITTED PAPERS_2r. PLANNING AND DEVELOPMENT SERVICES DEP
ARTMENT
S ' BUILDING AND CODE REGULATIONS DIVISION
: x 2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: ADDRESS: ! //✓ ��/00 ` a)' 4 C-
I, 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 //� �I-f-'Tzt1 4 CC
OWNE LDR R CONTRACTOR SIGNATURE
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Print Name
/ �, _ /f—/_7
DATE
STATE OF FLORIDA
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DAY OF , 20—n— .
By WHO IS PERSONALLY KNOWN TO ME , OR
HAS PROVIDED AS IDENTIFICAi);ON. LASHAHNA INGRAM-.
2�RY {G9,
YR� �n` Notary Public - State of Florida
E OF FLORIDA, County of _ « ° = My Comm. Expires Dec 20, 2018
:,� mo,
Commission # Ff 17724-9
'FOF Bonded through National Notary Assn.
IN'
URE OF NOTARY SEALr'�'�'
----------- —------ ------- —----- —---- -----------
=--------=----- —-------- --------- -- ---- —=------------
FOR OFFICE USE ONLY: sue'
Number of Open Inspections: 1 n
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage: ✓C v
Original permit fee: x % open = $ Renewal fee 1
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renew r.....,,_�
Revised 7/21/2014
SCANNED.
BY
St. Lucie County