HomeMy WebLinkAboutPermit Renewal RequestPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
J BUILDING AND CODE REGULATIONS DIVISION
•
2300 VIRGIN [A AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772)462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: 2006-0 14 ADDRESS: � �{J �y l +' `J1 CA0 9 A V C ( f)(
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
. 0 �+ :F� Z
OWNER/BLDR OR COAAACTO11,SIGNATURE DATE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF Sr LUCIE
ACKNOWLEDGED BEFORE ME THIS S_ DAY OF SUS ` 2021
BY DENNIS ZACEK WHO IS PERSONALLY KNOWN TO ME X OR
HAS PROVIDED
AS IDENTIFICATION.
STATE OF FLOR DA, Countyof ST LUCIE
t�yP. MIRANQAGILLIS
*. MY COMMISSION # KH 045659
SIGNATURE OF NOTARY SEAL EXPIRES: Septemlzer23,2024
Par v�g: Bonded Thru Notari Public Undeawrilets
FOR OFFICE USE ONLY:
Number of Open Inspections:
Total Inspections:
(Divide open by total to get ofo of open inspections)
Percentage:
Original permit fee: x % open - S Renewal fee
Example: [15 divided by 23=.65(0•0)] 5175(permit fee) x .65=$113.75 (renewal fee)
Revised 7 24:4