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DATE FILED: i 10 PERMIT# d3-05
REVISION FEE: RECEIPT#
PLANNING & DEVELOPMENT SERVICES
BUILDING&CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE,FL 34982-5652
(772)462-1553 FAX( 46
APPLICATION FOR BUILD
PROJECT INF TION
1. LOCATION/SITE '�7'�
ADDRESS:
2. DETAILED DESCRIPTION OF PROJECT
REVISIONS:
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3. CONTRACTOR INFORMATION:
STATE of FL REG./CERT.#: ST. LUCIE COUNTY CERT.#:
BUSINESS NAME: • \ (0Cdu l
QUALIFIERS NAME: N
ADDRESS: S
CITY: STATE: ZIP: 52_
PHiNE(DAYTIME): FAX:
4. OW7ER/BUILDER INFORMATION:
NAME: Qlb \
ADDRESS: SJr\3� LV`
CITY: STATE: ZIP:
PHONE: FAX:
5. ARCHITECT/ENGINEER INFORMATION:
NAME:
ADDRESS:
CITY: STATE: ZIP:
PHONE(DAYTIME): FAX:
Revised 07/22/2014
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ST.LUCIE COUNTY BUELDING D ,i ON
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