HomeMy WebLinkAboutREVISION FORM-INSTALLING A SECOND DISCONNECT OFFICE USE ONLY:
DATE FILED: _____________________________ PERMIT # _______________________________
REVISION FEE: ___________________________ RECEIPT # ______________________________
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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:
___________________________________________________________________________________
___________________________________________________________________________________
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
___________________________________________________________________________________
___________________________________________________________________________________
CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: ______________________ ST. LUCIE CO CERT. #: ____________
BUSINESS NAME: _________________________________________________________________
QUALIFIERS NAME: ________________________________________________________________
ADDRESS: _______________________________________________________________________
CITY: _______________________ STATE: _______________ ZIP: _______________________
PHONE (DAYTIME): ________________________ FAX: _____________________________
OWNER/BUILDER INFORMATION:
NAME: ____________________________________________________________________________
ADDRESS:__________________________________________________________________________
CITY: _____________________________ STATE: __________ ZIP: __________________
PHONE (DAYTIME: ___________________________ FAX: _____________________________
ARCHITECT/ENGINEER INFORMATION:
NAME: ____________________________________________________________________________
ADDRESS: _________________________________________________________________________
CITY: _____________________________ STATE: ____________ ZIP: ___________________
PHONE (DAYTIME): ___________________________ FAX: ____________________________
SLCCC: 9/23/09
Revised 06/30/17
This item has been signed and sealed byReyes Manuel Ruiz Donate, 88991PE on 7/6/2020using a Digital Signature.
Printed copies of this document are not considered signed and sealed and the SHA authentication code must be verified on any electronic copies.