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( fCgDATE FILED: \\-t`a�a�. PERMIT
REVISION FEE: RECEIPT# �d� a a 1
PLANNING & DEVELOPMENT SERVICES
BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE RECEIVED
FORT PIERCE, FL 34982-5652
(772)462-1553 NOV 12 2021
St,Lucie County
APPLICATION FOR BUILDING PERMIT REVISIONS rtlermimt ,
PROJECT INFORMATION
LOCATION/SITE
ADDRESS: 90 A�vTk f -
DETAILED DESCRIPTION OF PROJECT
! REVISIONS: .
CONTRACTOR INFORMATION:
STATE of FL REG./CERT.#: 6�C ST. LUCtF,60 CE T. #:
BUSINESS NAME: ru
j QUALIFIERS NAME: t
ADD SS: 7( .4OV
CITY V ( y4- STATE: ZIP:
PHONE (DAYTI E)F-,5," FAX:
OWNER(BUILDER INFORMATION:
NAME: (31. w ��.. i )Ce
ADDRESS: D 11
CITY: STATE: ZIP:
PHONE AYTIME:
j ARCHITECT/ENGINEER INFORMATION:
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NAME: J� ti-- t® �X-� l 1 ►4lis/� /�4.rN1 Y' La
ADDRESS:
CITY: STATE: ZIP:
PHONE (DAYTIME): ) FAX:
SLCCC: 9123109 C(I. I his f;
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Revised 06130/17
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