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PLANNING & DEVELOPMENT SERVICES �Fc�,
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE �qG
FORT PIERCE, FL 34982 o
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR,SUBCONTRACTOR OR CANCELLATION OF PERMT
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR—Change of Contractor is to be signed and notarized by the property owner,
and the new contractor of record for the current permit. A new permit application must also be completed with new
contractor information and signature. A new Notice of Commencement must be filed in the new contractor's name
for job values greater than $2,500 ($7,500 if A/C Change-out). A recorded copy must be submitted prior to
commencing any work.There is a$50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR—Subcontractor changes are to be signed by the general contractor only.
The new subcontractor must fill out a Subcontractor Agreement Form which is signed by both the contractor and
subco actor.There is a$50.00 fee for the Change of Sub-Contractor.
CANCELLATION OF PERXHT—The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: Igo cl Permit Number: 51-C11 D1Q-O(A
Site Address: For+ V i.erCP-1 'ICL 3ygyla
l Yt 2 F""n`e NODS/ e0. (XLI 9WA17n.ky' State License CGC I 514S'13 SLC License
Original GC,subcontract6r or owner/builder
State License SLC License
New GC,subcontractor or owner/builder
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and employees from all
costs,fees or damages arising from any and all claims of action for any reason,which may arise as a result of this change of
contr contractor or c cella' a-o permit.A pe7iii
lled if work en per fined.
SIG ATURE F o (r/builder) OR(or new GC,as applicable)
PRINT N �'4Qlj Q1 fGAsA. / u'r/� 51 a1 ,.e`
State of Florida,County of St Lucie County State of Florida,County of St Lucie County
The following instrument was acknowledged before me this The following ins ment was acknowledged before me this
day of #4 S4 2011 by ,-d'a/y of ff wq_,20l 1 by
f t �Kn� who is personally mown to me Lf(� SiAHner who is ersonally known to
or who has produced as ID. me or who has produced • as ID.
Signature of Notary,. Signature of Notary Date
TIMOTHY R.WALLEY
MY COMMISSION#GG 117135
TIMOTHY R.O'MALLEIf
Revised 05/18/x'= t i PIRES:August7,2021 =74'� *: MYtOMMISSION#GG 117135
, Bonded Thru Notary Public UndetwrtRers :a� (QIRES'August 7,2021
Bonded TIMI Notary PuNo Undomiters