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DATE FILED: / PERMIT# O 0��� /
REVISION FEE: S• O ! 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 P I 510N
PROJECT INFORMATION
LOCATION/SITE
ADDRE
DETAILED DESCRIPTION OF PROJECT
REVISIONS: &0
CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: ST. LUCIE CO CERT.#:
BUSINESS NAME:
QUALIFIERS NAME:
1 ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME): FAX:
OWNER/BUILDER INFORMATION::
NAME: Sh a l' � /-,' Jq h q z 4?e
ADDRESS: 1 S9✓r 0!�ar105 /r,
CITY: STATE: ZIP: 3 qfl/
PHONE (D YTIME:(77)-)-3 —7&,Uk FAX:
ARCHITECT/ENGINEER INFORMATION:
NAME:
ADDRESS:
CITY: STATE: ZIP:
PHONE (DAYTIME): -
RECEIVE®
SLCCC: 9123109
Revised 06130/17 JUN 13. 2019
Fji Permitting Department
Un�L P
mm `°M St. Lucie County, FL
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