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OFFICE USE ONLY:
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DATE FILED: \a1 1 2. PERA'IIT#
REVISION FEE: ���- RECEIPT#
PLANNING&DEVELOPMENT SERVICES
BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
(772)462-1553 —
APPLICATION FOR BUILDING PERMIT REVISIONS
PROJECT INFORMATION
LOCATION/SITE
ADDRESS:
9'9 0 H 6 Sr FaRr piER6-.5, fit. 3Y9$2
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
104,51SE REMOVE SERV i CC 0—HAN16-6 JrROM ►FERMI r-W1g0L
CONTRACTOR INFORMATION:
STATE of FL REGJCERT.#: off l? 60J 5I f 1 ST.LUCIE CO CERT.#:
BUSINESS NAME: C 14ARLE S �-Q WE t~L_ECTR I C� Inc.
(QUALIFIERS NAME: C H A R LES F-, 1-6wE
ADDRESS: AJ5.2 JjERNRAJQO T
CITY: FORT 1ERCE STATE: l- ZIP:
PHONE(DAYTIME): - 916to8 _ FAX:
OWNER/BUILDER INFORMATION:
NAME: Kim c a ADDRESS: q9 Lo EC-140, S T ti
CITY: 'FOR'T P I 'ERO-E STATE: Ft- ZIP: 314 l 8 2.
PHONE(DAYT 4E: r7r12 l -0 9 2 5 FAX:
ARCHITECT/ENGINEER INFOWNIA.TION:
NAME: N IA
ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME): FAX:
SL CCC: 9.23/09
IL — jj
Revised 06/30.117
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