HomeMy WebLinkAboutPermit DeferralOFFICE USE ONLY:
DATE FILED:
REVISION FEE:
PERMIT #
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: —� Q
DETAILED DESCRIPTION OF PROJECT
CONTRACTOR INFORMATION:
STATE of FL REG.ICERT.t 0/39 1)4-0(a 3-3 ST_ LUCIE �FyO CERT. #:
BUSINESS NAME: �� ��•. it c /� 4 C_ Uf
QUALIFIERS NAME:
ADDRESS: Z S ` t
CITY: .Sf' Le STATE: r_Z
PHONE (DAYTIN4E): � � J �, '� FAX:
OWNERIBUILDER INFORMATION:
NAME
ADDR
CITY:
PHONE (0A Y I I -ME:
ARCHITECT/ENGINEER INFORMATION:
NAME: [ .e
ADDRESS: Z�
CITY: f
PHONE (DAYTIME):
FAX:
'-Z
STATE:
_
'% 7J l FAX:
ZIP:
VA 19
SLCCC: 9123109
Revised 07117118