HomeMy WebLinkAboutPermit Renewals PLANNING ANIa 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
PERN11T NUMBER: -ao�_ ADDRESS:
1 Dennis Zacek 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 1 not receive a
passing inspection during any six month period during the renewal period.
Justification Ca), Ci 2]& (Ylc 1' �1 ,/�('CY>,�' Lao r-
OWNERIBLllR Q$CONTR f OR SIGNATURE PATE
Dennis Zacek
Print Name
STATE OF FLORIDA
COUNTY OF ST-- q ^ ' `
ACKNOWLEDGED BEFORE ME THIS�DAY OF {Y\t A .2011?
BY Dennis Zacek WHO IS PERSONALLY KNOWN TO ME X OR
HAS PROVIDED AS IDENTIFICATION.
S F FL *,T Lucie
01A : i""*N,: COLEEN SULLIVAN
SidNVUREMALO)An SEAL MY COMMISSION#GG071535
EXPIRES February 09,2021
FOR OFFICE USE ONLY:
Number of Open Inspections: 5 'oo
Total Inspections:
(Divide open by total to get°.o of open inspections)
Percentage:
Original permit fee: x%open = S Renewal fee
Example: [I5 divided by 23=.65(0/o)] $175(perrnit fee)x.65=$113.75(renewal fee)
Reviscd 7P-1014