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DATE FILED: u PERMIT# (9 12
REVISION FEE: � -��1_. RECEIPT#
PLANNING&DEVELOPMENT SERVICES
BUILDING&CODE REGULATION D '
2300 VIRGIN IA AVENU ,
FORT PIERCE,FL 34982- 5
(772)462.1553
l - APPLICATION FOR BUILDING PER T ISIO
PROJECT INFORMATION -
LOCATION/SITE
ADDRESS:
DETAILED DESCRIPTION OF PROJECT
REVISIONS:
CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: 4 b ST. LUCIE CO CERT. #:
BUSINESS NAME: r&kiri 0
QUALIFIERS NAME: r w r-
ADDRESS:
CITY: �:Se100' t\o"(-\ STATE: ZIP:
PHONE(DAYTIME): 7'715101 -S-14 3 FAX: Sc iMQ
OWNER/BUILDER INFORMATION:
NAME: i 1 c Ci t
ADDRESS: S2b
CITY: STATE: L ZIP:
PHONE (DAYTIME: `7`7 -���i FAX:
,ARCHITECT/ENGINEER INFORMATION:
NAME:
ADDRESS: G �,
CITY: DlgkboucaSTATE: ZIP:
PHONE (DAYTIME): 7 FAX:
SLCCC- 9/23/09 J
Revised 6/0 3 0/17 L� 1
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