HomeMy WebLinkAboutScanned from a Xerox Multifunction Printer.pdfPLANNING AND DEVELOPNIENT SERVICES DEPARTMENT
BUILDING AND CODE REGULATIONS DIVISION
•
- 2300 VIRGIN IA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMIT N;_"MB£R: - Z I O 5 - 410 (_ ADDRESS- l7"D�
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
0) ER/BLDR OR�NTRA�CTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
14 (Z� (Z l
DATE
ACKNOWLEDGED BEFORE ME THIS DAY OF� , 2021
By DENNIS ZACEK �V`FIO IS PERSONALLYKNOWN TO ME X , OR
HAS PROVIDED
STATE OF FLORIDA, County of ST LUCIE
SIGNATUR = OF NOTARY
FOR OFFICE USE ONLY:
Number of Open Inspections:.
Total Inspections:
(DiN-ide open by total to get ° o of open inspections)
Percentage.
Original permit fee: x °-o open = S Renewal fee
AS IDENTIFICATION,
RN MIRANQAGILLIS
,. MY COMMISSION 4 HH 046M
EXPIRES: September 23, 2024
SEAL '�cr % ?•' gp�aQ 7j�y jl y PAk urwewttm
Example. 115 divided by 23=.65(%' )] S 175(permit feel x .65=S l 13 75 (renewal feel
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