HomeMy WebLinkAboutRENEWAL 772-770-0064 ARS 19:26:53 07-11-2000 1/2
PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
..-. .:-..._;.._.......:._.._.......-..-.-. FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: !�'� 'n`'�'lJc� ADDRESS: J'T ,n,, h ✓t r E
I, inn i-sI reK ,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 G)l-e-n+ 14 - & af-(- rV1"irc--( m 46
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0 ERBLDR ORtONTRACTOR SIGNATURE DATE
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Print Name
STATE OF FLORIDA
COUNTY OF S.-
ACKNOWLEDGED BEFORE ME THIS_/�� DAY OF IU 204,4,_
BY �Dg�rjnl s7—ar-R'/ WHO IS PERSONALLY KNOWN TO ME / OR
HAS PROVIDED AS IDENTIFICATION.
S OF FLORID unty of
: :•`tw�i,-C-
BETH A DER13Y
SIG ATURE OF NOTARY •= MY coMmlPION a FF220930
'AOI M1
EXPIRES April 15.2019
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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(%)] $175(permit fee)x.65=$113.75(renewal fee)
Revised 7212014
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