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DATE FILED: 1/ l I l PERMIT# r3-0 9
REVISION FEE: RECEIPT# S;
"` PLANNING & DEVELOPMENT SERVICES
i BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE,FL 34982-5652
(772)462-1553 FAX(772)462-1578
APPLICATION FOR BUILDING PERMIT REVISIONS
PROJECT INFORMATION
1. LOCATION/SITE SfoK o
ADDRESS:
2. DETAILED DESCRIPTION OF PROJECT
REVISIONS:
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3. CONTRACTOR INFORMATION:
- STATE of FL REG./CERT.#: CGC t r-0 k Z ST.LUCIE COUNTY CERT.#:
BUSINESS NAME: _ C�SCJ 7 L-t� 79 f u m
QUALIFIERS NAME: 11A
ADDRESS: l-7 Z-o
CITY: <Z,V4"-a— STATE: rL ZIP: 3'1 %moi 5i
PHONE(DAYTIME): 44;?-Oily(, FAX: 5'7%�K
4. OWNER/BUILDER INFORMATION:
NAME: �n,�-moi �rLr^-o l�c.��✓�
ADDRESS: � r.(n O n 2
CITY: -sh.at ,z STATE: rti ZIP:
PHONE: - CJ 3 ( FAX:
5. ARCHITECT/ENGINEER INFORMATION:
NAME:
ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME): FAX:
Revised 07/22/2014
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