HomeMy WebLinkAboutPERMIT RENEWAL REQUESTPLANNING AND DEVELOPMENT SERVICES DEPARTMENT
COCINT'
r L 0 R j D A
BUILDING AND CODE REGULATIONS DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 Fax (772) 462-1578
PERMIT RENEWAL REQUEST
PERMITNI:MBER: ZlU7� T_ ADDRESS. L�01 W vi :f,t�j
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,
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 _LqS-�- CnUV i _ Q( c&X (
Dsu" 3MIL
OWNER/BLDR OR MNTRACTOR SIGNATURE
DENNIS ZACEK
Print Name
STATE OF FLORIDA
COUNTY OF sT LUCIE
ACKNOWLEDGED BEFORE ME THIS ._ DAY OF CAV't' F
BY DENNIS ZACEK
HAS PROVIDED
STATE OF FLORIDA, County of ST LUCIE
SIGNATUR OF NOTARY
FOR OFFICE USE ONLY:
!I�-[ZZ.
DATE
, 20
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 = 5 Renewal fee
AS IDENTIFICATION
"w+►a MIRANDAGILLIS
MY COMMISSION # HH 045659
e P� EXPIRES: September 23, 2024
SEAL ''•csi?0' BondadThruNolaryW66eUndenHilera
Example: (15 divided by 23=.65(%)] S l75(permit fee) x .65=S i 13 75 (renewal feel
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