HomeMy WebLinkAboutScanned from a Xerox Multifunction PrinterPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
rt COUNTY BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT NUMBER: 60FS — b 2-4 Z
PERMIT RENEWAL REQUEST
ADDRESS: Re 6h
I, DENNIS ZACEK am requesting that the above permit be renewed. I
understand that I must schedule and pass ail 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
OWNER/BLDR OR CONT CTOR . IGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF $T wcit_
ACKNOWLEDGED BEFORE ME THIS Z
BY DENNIS ZACEK
HAS PROVIDED
`IIZt(zI
DATE
DAY OF <)U � UI , 2021
WHO IS PERSONALLY KNOWN TO ME X , OR
AS IDENTIFICATION.
ST TE OF ORIDA, County of ST LUCIE
MIRANDAGILLIS
MY COMMISSION # HH 045659
SIGNATURE OF NOTAR SEAL =+ ...,. 4 EXPIRES: September23, 2024
ROF FLq: Bonded Thru Notary Public unda wltten3
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(%)J $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7 21.:2034