HomeMy WebLinkAboutVoid Permit request _ PLANNING& DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
° 2300 VIRGINIA AVE
o
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
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-
r.
7ancellation
CANCELLATION OF PERNIIT—The cancellation of a permit is acceptable only if no work has been done.
ellation of permit is to be signed andnotarized by both the owner and qualifier of record. There is no fee for
of the permit.
Date: 11-20-19 Permit Number: 1910-0061
SiteAddress: 3210 South Lakeside Cir,#3106
Shyan Wojtczak/Cool Air Solutions of Florida, Inc. State License CAC#1819009 SLC License
Original GC,subcontractor or owner/builder
State License SLC License
New GC,subcontractor
Reason for Cancellation Homeowner is going with another company
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 o cancellation of permit.A permit cannot be cancelled if work has been performed.
Yh C;�4� U
SIG TURE O R(or owner/builder) SIGNA GENERAL CO TOR(or new GC,as applicable)
PRINT NAME � AU' �s PRINNTNAME Shyan Wojtczak
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 following instrument was acknowledged before me this
Z O day of J✓ 20A(( by 7-0 day of KJ W 20 1 by
ld-m�l S✓P /141Y(/wkib w� �62
is personally known to me S1�1�!� � who is personally known to
r ho has produced as ID. me or who has producedLas ID.
11-20-19 11-20-19
Signature of N ry Date Signature of Notary/ Date
o�"""Pie
HEATHER BURFORD
Revised 04/15/16 HEATHER BURFORD =2 ;State of Florida-Notary Public
QBE Commission# GG 183217
State of Florida-Notary Public
,i ''�fOPF��-, My Commission Expires
*= Commission # GG 183 l �,������ February 06, 2022
a d My Commission Expiresto
February 06,