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PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE 'to
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
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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 completed by the general contractor.
The new subcontractor must fill out a Subcontractor Agreement Form. Thereis a$50.00 fee for the Change of Sub-
Contractor.
1191"13 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.
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Date: Permit Number: 1707-0589
0
Site Address: 8590 Carlton Rd.Port St Lucie,FL 34987
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The Home Depot State License CGC1514813 SLC License
Original GC,subcontractor or owner/builder
State License SLC License
New GC,subcontractor
Reason for Cancellation Conflicts with scheduling
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and employees from all
co damages arising f om a nd laims of action for an reason,which may arise as a result of change of
ontractor/su contractor or nce t' permit.A p ► cannot be can lied if work has a rf med.
SI ATURE O (or owner/builder) SIGNATURE ERAL C TRACTOR(or new GC,as applicable)
PRIN AME Ct �C���/vE.� PRINT NAS
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following instrument was acknowledged before me this Thffollowing instryment was acknowledgebefore me this
L IKday of 5t p T .20k� ,by 4 µ day of 55^^CC E ,20�Z,'6y t4&1
S rN�Kvt-c r who is personally known to me 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
.•��. TIMOTHY R O'MALLEY
Ito
iOP:sed /Q�rb'>*t. TIMOTHY R.O'MALLEY *�R•• *: MY COMMISSION#GG 117135
MY COMMISSION#GG 117135 =�;, EXPIRES:August 7,2021
A Bonded Thru Notary Public Undervrtiters
EXPIRES:August 7,2021
Bonded Thru Notary Public Undenxrilers