HomeMy WebLinkAboutProperty Identification PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE RECEIVED l
FORT PIERCE, FL 34982 I
JUL 0
(772) 462-1553 FAX 462-1578 ? ?9
ST. Lucie County, Pcrrnittinq
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. There is a$50.00 fee for the Change of Sub-
Contractor.
x E� 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: 6/13/2019 Permit Number:���
Site Address' X 3810 ELEVEN MILE RD FT. PIERCE,FL 34945
State License SLC License
Original GC,subcontractor or owner/builder
JBR EXTERIORS, INC./JEREMIAH JOHNSON State License CBC1260687 SLC License
New GC,subcontractor
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
contractor/subcontr or or cancellation per A rmit cannot be cancelled if work has been performed.
SIG OF OWNS or ownedbuilder) / SIG ATURE ORAL CONTRACTOR(or new GC,as applicable)
PRINT NAME � il ()�/d!✓ PRINT NAMEcJeCls�^✓tih ��1°Scs
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_fpllowing instrument was acknowledged before me this
—day of�J� 20A by - day of�20A by
(( who is t ersonally known t me who is perso Ino to
or who pd ced as ID. me or who has produced as ID.
6/13/2019 6/13/2019
Si lure of Notary Date Signature of Notary Date
Revised 04/15/16 :o40 h4y� Notary Public State of Florida Notary Public State�OfFlorldaJoshua Shane Alberico Joshua Shane AlcoMy Commission GG 020879 My Cammit+lion OG0879
-OF*%:�p Expires 08/16/2020 � BxplrOl 08/16/2020