HomeMy WebLinkAboutPermit renewalPLANNING 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
PERMIT NUMBER: W 09 — 04 (Z ADDRESS: SOOG P'Ir P-rson 'i7(
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 (`,t Q. ( n1Y-"U vqtd A b SC k4d i e 1 K PgC t00
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OWNERIBLDR OR CONTRACTOR SIGNATURE DATE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LuaE
ACKNOWLEDGED BEFORE ME THIS 2 S DAY OF C _, 2021
BY
DENNIS ZACEK
HAS PROVIDED
STATE O LORI A, County Of ST LUCIE
SIGNATURE OF NOTARY
FOR OFFICE USE ONLY:
WHO IS PERSONALLY KNOWN TOME X , OR
Number of Open Inspections:
Total Inspections:
(Divide open by total to get % of open inspections)
Percentage:
Original permit fee: x % open = $ Renewal fee
AS IDENTIFICATION.
t""" MIRANDAGILLIS
MY COMMISSION # HH 0�202]41
SEAL EXPIRES: September 23,jj�
8endedThru Notary Pubtit und
Example: [l5 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7-21-1014