HomeMy WebLinkAboutPermit Renewal PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
3 `T 6 BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE,FL 34982
(772)462-1553 Fax(772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 6-0q zO ADDRESS: ii(OO kjckTQ k l e D('
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 I not receive a
passing inspection during any six month period during the renewal period.
Justification Permit Expired
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OWNER/BLDR off
p6NTRACTOR SIGNATURE DATE
Dennis Zacek
Print Name
STATE OF FLORIDA
COUNTY OF s+Lcounty
ACKNOWLEDGED BEFORE ME THIS 2'7—DAY OFA ,20�Q_
BY 1 ��+ U11CK WHO IS PERSONALLY KNOWN TOME OR
HAS PROVIDED Drivers License AS IDENTIFICATION.
*SIGATURE'OF
F FORI ,COL111ty of � Lobe- C oU�V MELISSA CHATEAUNEUF
State of Florida-Notary Public
Commission#GG 340178
NOTARY SEAL [my Commission Expires May 30,2023
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Revised 7!2 02014