HomeMy WebLinkAboutPermit renewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
r 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: 200-1 l ADDRESS: _1O,b S OCIEYN C<��b,
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 LADSk %OVA (� I
OWNER/BLDR OR CO ACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF ST LUCIE
6 1 ZiS i zk
DATE
ACKNOWLEDGED BEFORE ME THIS 7&5 DAY OF J( ) Vyy , 2021
BY DENNIS ZACEK
HAS PROVIDED
STATE OF f LORIDA, County of ST LUCIE
W&4�4-�
SIGNATUR OF 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 = $ Renewal fee
AS IDENTIFICATION.
MIRANDAGtLLIS
MY COMMISSION # HH 045659
o EXPIRES: September 23, 2024
�rFo2�Q��:
SEAL r Bonded Thru Notary Public Underwrilem
Example: [15 divided by 23=.65(%)] S 175(permit fee) x .65=$113.75 (renewal fee)
Revised 7:2112014