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OFFICE USE ONLY:
DATE FILED: �' J 7' PERMIT#
REVISION FEE: J ' d'1. RECEIPT#
PLANNING &DEVELOPMENT SERVICES
BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
° FORT PIERCE,FL 34982-565
--- - (772)462-1553 FAX(772)462-1 8
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APPLICATION FOR BUILDING PE I
AP
PROJECT INFORMATION
1. LOCATION/SITE
ADDRESS: V I yu C�
2. DETAILED DESCRIPTION OF PROJECT
REVISIONS:
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3. CONTRACTOR INFORMATION:
STATE of FL REG./CERT.#: l I ST.LUCIE COUNTY CERT.#:
BUSINESS NAME:
QUALIFIERS NAME:
ADDRESS: z) kao
CITY: Q LLktk�k STATE: ZIP:
PHONE(DAYTIME):-na-%71?-I-- ) 1 FAX:
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4. OWNERBUILDER INFORMATION:
NAME: ?
ADDRESS: is5m p r r,i
CITY: STAT ;'
PHONE: J'FA r .
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5. ARCHITECT/ENGINEER
INFORMATION:
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NAME: VAS( Jam '{
ADDRESS: k-glax:R i .„ f k ..3 ' A
CITY: lJ. STA ..• tt ' r'i `s✓- _ ' ZIP:'
PHONE(DAYTIME): _ �D�r FAX:
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Revised 07/22/2014 FU-9
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APR 2'7 2017