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DATE FILED: PERNIIT# e ZDO 1 - C�
REVISION FEE: RECEIPT#
PLANNING&DEVELOPMENT SERVICES
BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE,FL 34982-5652
(772)462-1553
APPLICATION FOR BUILDING PEI
PROJECT INFORMATION
LOCATION/SITE
ADDRESS:
c� g I o W� � Ct< < �c
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
(f d'4�j C!E P Ti C A2a1-111 &�C1e-,r-1Za
2W-04 f-\-L' 9A
CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: ST. LUCIE CO CERT. #:
BUSINESS NAME: _Lb U P er s �o1.f� oc��, /iVC
QUALIFIERS NAME: 20 6,z.re-r 5, f32ut-jrS
ADDRESS: 4.3D(- U5 -f-
CITY: - 'r F 1 )-fqz . STATE: ZIP: C379' Z
PHONE(DAYTIME): '77 -2-- 4,tL S'- Z 7 D o FAX: 7 7 Z 44G 5-1,n6 3
OWNER/BUILDER INFORMATION:
NAME: tj / 4
ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME: FAX:
ARCHITECT/ENGINEER INFORMATION:
NAME:-- k)I f}
ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME): FAX:
SLCCC: 9/23/09
Revised 06/30/17