HomeMy WebLinkAboutrenewalPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
•
' BUILDING AND CODE REGULATIONS DIVISION
- 2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772)462-1553 Fax (772) 462-1578
PERMIT Ni- MBER: Zoo
PERMIT RENEWAL REQUEST
ADDRESS: 123 S tW(A
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 �_{y ,y j �)
0 -
OWNER/BLDR OR 06NTRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
it IZG tzk
DATE
ACKNOWLEDGED BEFORE ME THIS Z`O DAY OF 0\3t i] ,102'I
By DENNIS ZACEK
HAS PROVIDED
STATE OF FLORIDA, Countyof ST LUCIE
SIGNATI R OF NOTARY
WHO IS PERSONALLY KNOWN TO ME X . OR
- ------- - -------- -
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 = S Renewal fee
AS IDENTIFICATION.
a�.►ri MIRANDAGILLIS
MY COMMISSION # HH 045M
�W EXPIRES: September 23, 2024
SEAL sondedihmNotoyPubkUndennrtters
Example: [15 divided by 23=.65(%A S 175(permit feel x .65=5I 13.75 (renewal feel
f(evrsea r LI-LUt4