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DATE • /
DATE FILED: �• D k\7
REVISION FEE: _ --a- ty_
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PERMIT # v a - Q d
RECEIPT #
PLANNING & DEVELOPMENT SERVICES
BUILDING & CODE REGULATIO I
2300 VIRGINiA AVE
FORT PIERCE, FL 34982-SMM IC
(772) 462-1553 FAX (772) 4621W7A
APPLICATION FOR BUILDING
PROJECT INFORM,
LOCATION/SITE ( �J
ADDRESS: d 56- �j , ff
DETAILED DESCRIPTION OF PROJECT St. LucBY ie Count
REVISIONS:
3. CONTRACTOR INFORMATION:
STATE of FL REG./CERT. #: C / 0 D 16 ST. LU
BUSINESS NAME:
QUALIFIERS NAME:
ADDRESS: c
CITY: STATE:
PHONE (DAYTIME): 77.l - *,4_O 7 / � FAX:
4. OWNER/BUILDER INFORMATION:
5.
NAME:
ADDRESS:
CITY:
PHONE:
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NAME:
ADDRESS:.
CITY:
PHONE (D)
Revised 07l2 914
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COUNTY CERT. 3 5
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STATE: ZH': 3 3 3
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IRECEIVE
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