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PLANNING & DEVELOPMENT SER
BUILDING & ZONING DIVISION
�' 2300 VIRGINIA AVE
FORT PIERCE_, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR, SUBCONTRACTOR OR CANCELLATION OF PERMT
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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 completed by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. There is a $50.00 fee for the Change of Sub-
Contractor.
_CANCELLATION OF PER T—The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signedl. ed by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: Permit Number: ;SLC1705-0616
Site Address: _790 SW Ar ro S o AIVA Po rLlnei , FL. 3y6(SS
The Home Depot/Raquel Swanner State License CGC1514813 SLC License
Original GC, subcontractor or owneribuilder
State License SLC License
New GC,subcontractor
Reason for Cancellation Customer decided to cancel contract prior to the start of any work
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and employees from all
costs ees or damages aris' g from any and all claims of action for any reason,which may a a result .this change of
ontrac r/subcontr t r c c lation of permit.A permit ca a ca celled if wor s een formed.
IGNO or owner/builder) IGNA CON CTOR(or new GC,as applicable)
PRI P NAME PRINTNAME
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie Founty
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The following instrument was acknowledged bete-,91
e a The following instrument was acknowledged before me this
day of 20by day of 20_,by
who is personally known to m� who is personally known to
or who has produced as ID. me or who has produced as ID.
Signature of Notary Date Signature of Notary .Date
FY pU• .•S;PY Pv, TIMOTHY R.O'MALLEY
•<�...,s'•. TIMOTHY R.O'MALLEY ��.:
Revised 04/ = 6 °°*_ MY COMMISSION#GG 117135 MY COMMISSION#GG 117135
;9rp EXPIRES:August 7,2021 ��;� EXPIRES:August 7,2021
•'•ry0rt F���• Bonded ThN Notary Public Underwriters '�P,F;;g`•• Bonded Thru Notary Public Underwriters
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