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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 REVISIONS
PROJECT INFORMATION
LOCATION/SITE
ADDRESS: 2
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
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CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: ST. LUCIE CO CERT. #:
BUSINESS NAME: h e n C� N 12,)o ,--i •N 6 GV" . r-S " V.
QUALIFIERS NAME: '6lq5 n u/N O SC n V 0 V'
ADDRESS: Zo 1 6
CITY: Fov c, V-L STATE: Ft ZIP: 3 � C)
PHONE (DAYTIME): Z — 3 3 3 l4 FAX:
OWNER/BUILDER INFORMATION:
NAME: My I S
ADDRESS:
CITY: arSTATE: �/L
PHONE (DAYTIME: FAX: _
ARCHITECT/ENGINEER INFORMATION:
NAME:
ADDRESS:
CITY:
PHONE (DAYTIME):
SLCCC: 9123109
Revised 06130117
STATE:
1' AL1.
ZIP: `3 ,1 9 s
ZIP: