HomeMy WebLinkAboutPermit RenewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
s
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER:'ZOO — O11 O ADDRESS: l D 1 (41 yy Ck �h TO C'd N -
I, 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 abk` C 1C ry)wk� C 0
-D,�Pit/A'1- L Z Z i Z
OWNER/BLDR OR CONTRACTOR SIGNATURE DATE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
ACKNOWLEDGED BEFORE ME THIS Zz DAY OF [ " , 2021
BY DENNIS ZACEK
HAS PROVIDED
STAT k OF V ORI A, county of ST LUCIE
SIGNATUR1, F NOTARY
FOR OFFICE USE ONLY:
WHO IS PERSONALLY KNOWN TO ME X OR
Number of Open Inspections;
Total Inspections- _
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = S Renewal fee
AS IDENTIFICATION.
MIRANDAGILLIS
MY COMMISSION # Fi>a 045659
EXPIRES: September 23, 2024
SEAL °`f`'' BondedTluuNetaiyPubreU9&-rwdtem
Example: [ l5 divided by 23=.65(%)] S175(permit fee) x .65=5113.75 (renewal fee)
Revised 7 21F2014