HomeMy WebLinkAboutRENEWAL FORM, 8.19.20PLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY
F L O R 1 b A
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 1510 r _ ADDRESS: C 1 U� wa Qd
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
OWNER/BLDR O NTRACTOR SIGNATURE DATE
Dennis Zacek
Print dame
STATE OF FLORIDA
COUNTY OF Si Lucie. County
ACKNOWLEDGED BEFORE ME THIS l DAY OF m S� 20
BY 14(75U`(�QQV)"WHO IS PERSONALLY KNOWN TOME OR
HAS PROVIDED Drivers License — AS IDENTIFICATION
ST E OF FLORIDA, County of. .. \ Lv 1t CounAq MELISSA CHATEAUNE]2023
State of Florida - Notary Pub
Commission # GG 34017
SIGNATURE OF NOTARY SEAL My Commission Expires May 30
L.A[lilivkL. t1J lllr LU%..0 Vy 6J .VJ1. U�j .yl I1 lli 11 ILA.) A .UJ-.pi lj,/J klt-i vv Al t61.)
Revised 7:21?2414