HomeMy WebLinkAboutPermit RenewPLANNING 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 NUMBER:
1'10t -6 t-L t
PERMIT RENEWAL REQUEST
ADDRESS: _ r O1 C �5 �' 1 or
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 Coo 4-0 C t d 9-C.—
OWNERIBLDR OR CO ACT R SIGNATURE DATE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF ST LUCIE
ACKNOWLEDGED BEFORE ME THIS '7.,5. DAY OF � kj o'A' , 2021
BY DENNIS ZACEK
HAS PROVIDED
STATE OFF ORIDA, County of ST LUCI E
SI NATUR O ARY
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 = $ Renewal fee
AS IDENTIFICATION.
MIRANDAGILLIS
A*'--,-; MY COMMISSION 0 HH 045659
o;= EXPIRES: September23, 2024
SEAL 'FOF �qe' Bonded Thru Notary Public Underwriters
Example: [ 15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 12112014