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OFFICE USE ONLY:
DATE FILED:Tl PERMIT #
REVISION FEE: • ,3 BY RECEIPT # h Ga l l
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PLANNING & DEVELOPMENT SERVICES
BUILDING & CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982-6662
(772) 462-1553
APPLICATION FOR BUILDING PERMIT REVISIONS
PROJECT INFORMATION
LOCATION/SITE
ADDRESS: 5 7 O C, 0 �
& r k l l c,CG 2 i F L. 3
DETAILED DESCRIPTION OF PROJECT
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CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: C,&C -jS � )-9 j q ST. LUCIE CO CERT. #:
BUSINESS NAME: �f�o.�,c�r� i'�o-5� (-�r► ���` C� ..1-��� art , LL C .
QUALIFIERS NAME:
ADDRESS: _1 7 10 G �,�r,�.���� a A
CITY: r" r-4 1� i G �� STATE: F L- ZIP: 2 cq 5 z-(
PHONE (DAYTIME): (-7Z) aot - 5 -t 2 FAX:
OWNER/BUILDER INFORMATION:
NAME: _
ADDRESS:
CITY:
PHONE (DAYTIME:
STATE:
ARCHITECT/ENGINEER INFORMATION:
NAME: A r Gt. % V c- e-l- o :.L
ZIP:
ADDRESS: O L, - („ Avt-
CITY: rl- %,)� br6e- STATE: l- ZIP: 3 cI q t Q
PHONE (DAYTIME): '-77 7' I -L �l G 9
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SLCCC. 9123109 r
Revised 06130117 REVISION