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PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(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
j commencing any work. There is a$50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR—Subcontractor changes are to be completed1by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. There'is a$50.00 fee for the Change of Sub-
C ntractor.
CANCELLATION OF PERMIT—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: El 1� 1� Permit Number:
Site Address:
C` / l L State License C License
I Original GC,subcontractor or owner/builder
i
State License SLC License
New GC,subcontractor
Reason for Cancellation V\� ,`1�
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
contractor/subcontractor or cancellation of permit.A permit cannot be cancelled if work has been performed.
SIGNATURE OF OWNER(or owner/builder) SIGNA GENNfRRAL O TRACTOR(or new GC,as applicable)
PRINT NAME PRINT _�{ J� g 4-o �) i
State of Florida,County of St.Lucie County . State of Florida,County of St.Lucie County
i
The following instrument was acknowledged before me this Te ollowing instrument was acknowledged before me this
day of 20_,by , day of 20_L-I;by
who is personally known to me ho is personally known to
or who has produced as ID. 3-t-re
ho has produced ;i
as ID.
Signature of Notary Date of Notary Date
i
Revised 04/15/16
i' LASHAHNA INGRp�y
Notary public_State o!Florida_
A!y Comm.Expires Dec 20, r!;g
COMM188 04�f;_;_
a0nded throw,,,.