HomeMy WebLinkAboutrenew formPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: &X-1 — 00LO ADDRESS: Z35k Zd
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 Ou-.m 4uac (N + I }OSr— GL.(du(E
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O R/13LDR OR CONTRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF ST LUCIE
11 1 Z -1 1 Z)
DATE
ACKNOWLEDGED BEFORE ME THIS Z-7 DAY OF 1 2021
By DENNIS ZACEK WHO IS PERSONALLY KNOWN TO ME X , OR
HAS PROVIDED
STATE OF FLO DA, County of ST LUCIE
SIGNATURE OF NOTARY
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
AS IDENTIFICATION.
;�O`•'�A MIRANDAGILLIS
MY COMMISSION # HH 045659
r o�= EXPIRES: September 23, 2024
SEAL :�oF R °�' Banded Thru Hwy Public Underwriters
Example: [ 15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7`21f2014