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III PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
f Y
FORT PIERCE, FL 34982
(772) 462-1553 .FAX 462-1578
CHANGE OF CONTRACTOR SUBCONTRACTOR OR CANCELLATI N OF PERMIT
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR-Change of Contractor is to be signed and notari d 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 musl 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 t y 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 PERMIT-The cancellation of a permit is acceptable only i no work has been done..
.Cancellation of permit is to be signed and notarized by both the owner and qualifier of rec rd. There is no fee for
cancellation of the permit.
Date: I - 3k.- 19 Permit Number: `3 L-Q- 1509 - L
Site Address:
ARPWIM ' State License SLC License
Original C,subcontractor or owner/builder
State License SLC License
,
New GC,subcontractor
Reason for Cancellation -t 7;1461- REV 100-1f)L-Lb �� S
The undersigned does herebyagree to indemnify and hold harmless St Lucie County,its officers,age n and employees from all
costs,fees or damages arising from any and all claims of action for any reason,which may arise as art ult 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) GNATURE GENERAL CONTRACTOR(or n ow GC,as applicable)
PRINT NAME PRINT NAME S r S
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following instrument was acknowledged before me this following i rument was acknowledged be re me this
day of 20_by day o ��� V 20]5 by 5
who is personally known to me I)L who is personalli 1Ww to
or who has produced as ID. me or who as produced as 11).
Signature of Notary Date Signs tpg4f No ry Date
SPRY PUB
ANGELgYOU G
Revised 04/15/16 �y� ror'
A0 �:�✓f� l rT�Q * * MY COMMISSION 0 F 951069
EXPIRES:AprO 12 2W
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