HomeMy WebLinkAboutrenwal requestPLANNING 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:
ICkb- 415Z_
PERMIT RENEWAL REQUEST
ADDRESS: ZC: O
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 i t �-t ccx
ftz[zI
OWNER/BLDR OR CO_ ACTOR SIGNATURE DATE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
ACKNOWLEDGED BEFORE ME THIS � DAY OF \je � , 2021
BY DENNIS ZACEK _ WHO IS PERSONALLY KNOWN TO ME X OR
HAS PROVIDED
AS IDENTIFICATION.
STATE OF FLORIDA, County of ST LUCIE
MIRODAGIWS
*, f, AdY C41y1MISSION # HH 045659
SIGNATURE OF NOTARY SEAL IAEXPIRES: September 23, 2024
J4,Me; BMW 11Yu Notary pw* Ifidmabra
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
Example: [15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7 '21 : 2014