HomeMy WebLinkAboutREQUEST TO RENEW PERMIT LETTER�6�Qp
COUNTY`
F L U R I D A'
PLANNING 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: Z00C1-0(vOZ ADDRESS: Lps jc qs�
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 C. Ste. ir�
rig
0 _
OWNER/BLDR OR G TRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
V• -k C6
16 t z ( / 7,
DATE
ACKNOWLEDGED BEFORE ME THIS V DAY OF _ C4,01Z�1 2021
BY DENNIS ZACEK
HAS PROVIDED
STATE OF FLORIDA, County of ST LUCIE
SIGNATURE OF NOTA
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 = S Renewal fee
AS IDENTIFICATION.
INC
SEAL EMIRAMDAGILUS
SEAL ,.o, RE3:Seplember23,2024
7fw Notary pubpe �
Example: (15 divided by 23=.65(%)] S 175(permit fee) x .65=$113.75 (renewal fee)
Revised 7 21 2014