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DATE FILED:
REVISION FEE:
PERMIT # A&"; ^ G) z
RECEIPT #
PLANNING & DEVELOPMENT SERVICES
BUILDING & CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-5652
(772)462-1553
APPLICATION FOR BUILDING PERMIT DEFERRAL
PROJECT INFORMATION
LOCATION/SITE
ADDRESS: r
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3 Ye�,
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: C % Gd ST. LUCIE CO CERT. #:
BUSINESS NAME: L1 ^ G
QUALIFIERS NAME: , / c- � a u" �u 4
ADDRESS: q / ' (" r !"
CITY: /jC rc i"U 5 STATE. -
PHONE (DAYTIME): r} - ' ri - 6• Q ! FAX:
OWNER/BUILDER INFORMATION:
NAME: L V
ADDRESS: G
CITY:
PHONE (DAYTIME:
ARCHITECT/ENGINEER INFORMATION:
ZIP:
Y
NAME: l t.� h �C4� L (2, K6u
ADDRESS:
CITY:. STATE: ZIP:
PHONE (DAYTIME): 3'5 - Y6 L ! FAX:
SLCCC: 9123109
Revised 07/17118