HomeMy WebLinkAboutPermit Renewals PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT MEAD,FL 34982
(772)462.1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERK=NUMBER - 1 to 5 ADDRESS: Du ar-1 IV + D 2y
I, TV i n 181 d SQ n ,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,Y
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. % Cf- 5t-G1Ff CC,?�4a� ��0DOM f�1Gt�� i��QeGfiUtn
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OW9ER/ALDR OR CONTRACTOR SIGNATURE DATE
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Print Name
STATE OF FLORIDA
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ACKNOWLEDGED BEFORE ME T141S DAY OF e�C�L� Lu_a,(�m 120
sy t�i`m i�l4( WHO IS PERSONALLY KNOWN TO ME V" ,OR
HAS PROVIDED AS IDENTIFICArTON,
STA OF ORIDA,Cour of
SIGNATURE OF NOTARYW COMMISSION k FF904048
EXPIRES July s1,2010
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1v OR OF'F'ICE 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: [IS divided by 23=.65(0/.)] $175(permit fee)x.654113.75(renewal fee)
Revised 7/2112014
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