HomeMy WebLinkAboutPermit renewal formPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL.34982
(7722) 462-1553 Fax (772) 462.1579
PERMIT NUMBER: to 0-1- Od z k
PERMIT RENEWAL REQUEST
ADDRESS: I S 7i I �-3 Lf 5k41
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 _C,c srpjnE� S.. ..kd (' >17 cat 01 0wt•�
OWNERALDR Q@ CO OR SIGNATURE
Dennis Zacek
Print Name
STATE OF FLORIDA
COUNTY OF ar Lud.
ACKNOWLEDGED BEFORE ME THIS 22 DAY OF December
BY Dennis Zacek
HAS PROVIDED
STATE OF LORI A, County of St Lucie
SIGNATURE OF NOTARY
12/22/2020
DATE
WHO IS PERSONALLY KNOWN TO ME
2020
X ,OR
AS IDENTIFICATION
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SEAL ?J�o�i,�l��` EXPIRES: September 23.2024
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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(%)] S 175(permit fee) x _65-S 113 75 (renewal fee)
Reviscd 7/21:2014