HomeMy WebLinkAboutPermit renewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
. 2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: Z00(0 —a 35_ ADDRESS: SC` -i V-� �kLgV)WCAL f Ac A
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 4f:,d �-k(A �JomX awuLv r(
14
OWNER/BLDR OR CONTRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sr WCIE
Ll lZ,6 ( 7 l
DATE
ACKNOWLEDGED BEFORE ME THIS DAY OF 1'31� L \ , 2021
BY DENNIS ZACEK WHO IS PERSONALLY KNOWN TO ME X , OR
HAS PROVIDED
STnwAq
SIGNATURE OF NOTARY
of ST LUCIE
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 = S Renewal fee
AS IDENTIFICATION.
ice+?u MIRANDAGILLIS
MY COMMISSION 0 HH 045659
�• b EXPIRES: September 23, 2024
SEAL "y'FoF i ?P' Bonded 1tw Notary Public Ur&AWiters
Example: 115 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7.+2112014