HomeMy WebLinkAboutScanned from a Xerox Multifunction PrinterPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COUNTY BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT NUMBER: G CS ( I_ -00t-S ADDRESS: 1 ,-) C4 T- Z
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 1A A r Con1 ac' ' ow V.0 fr
OWNERIBLDR OR CGhrRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
I1 h7-IZ[
ACKNOWLEDGED BEFORE ME THIS IZ, DAY OF OveMble, `
DATE
BY DENNIS ZACEK WHO IS PERSONALLY KNOWN TO ME
HAS PROVIDED
STATE OF FLORIDA, C..nty of ST LUCI E
SIGNATU RrLKWTARY��
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
, 20 21
X OR
AS IDENTIFICATION.
frti►'t ^1;,: MIRANI>AGILLIS
,. .*; h4Y COMMISSION 0 HH 045M
=? , EXPIRES. September 23, 2024
SEAL '.;?rjr�*c'`', BaideGTtauNoWyPubRetfida+ts
Example: [ 15 divided by 23=.65(%)] $175(permit fee) x .65=$113.75 (renewal fee)
Revised 7/21+2014