HomeMy WebLinkAboutrenewal requestPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
COUNTY
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMITNUMBER: 1912-0270 ADDRESS.481 HEMINGWAY TER
1, DENNIS ZACEK , am requesting that the above permit be renewed. I
understand that I must schedule and pass la required inspections for the permit to be ftnaled. 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 CUSTOMER HAS BEEN OUT OF STATE DUE TO COViD-19
-ar'(_ 11/30/2020
OWNEWBLDR OR CONT QR SIGNATURE DATE T
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF FLORIDA
ACKNOWLEDGED BEFORE ME THIS 30 — DAY OF NOVEMBER , 2020
BY DENNIS ZACEK WHO IS PERSONALLY KNOWN TOME _ X ..._., OR
HAS PROVIDED
STATE OF FLORIDA, County of ST LUCIE
SIGNATURE OF NOTARY
AS IDENTIFICATION,
SEAL
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get ° o of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
Example: (15 divided by 23-.65(0ri)] 5175(permit fee) x .65-3113.75 (renewal fee)
Revacd 7121/2014