HomeMy WebLinkAboutCancellationJun 10 20, 09:31a Treasure Coast Roofing 7723438368 p.1
PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
• 2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1.578
CHANGE OF CONTRACTO SUBCONTRACTOR OR CANCELLATION OF PERMIT
-,�s3a-�6Da_oat9-ata_9 �`�-✓>\e.-{ql
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 S2,500 ($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 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
cauceilatiou of the permit.
Date: C/ $/fib
Permit Number:
16oa 0y94
Site Address:
,v
lrtaivrt nnf—Odat/h°� State License C GCLC License
Original GC, subcontractor or owner/budder
New GC, subcontractor
Reason for Cancellation
License SLC License
rk C/o.1•G
The undersigned does hereby agreeto indemnify and hold harmless St Lucie County, its officers, agents and employees from
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 or cancellation of permit. A permit cannot be cancelled if work has been performed.
SIGNATURE OF OWNER(orowneJuilder) SIGNAT ' O. TOR (or rlc r//G��jjC, as rppli¢ble)
PRINT NA14E PRINT NAW- e, kW � �-�
State of Florida County ofSL Lucie County
The following instm ant sves aclorowlodged bcfor me this
2o— by
_who is Personally !mown to me
or Wio has products as ID.
Signature of Notary Date
Revised 04/15/16
State of Florida, County of St. LucieCounly
The follouing instrument mw oclmo,,4cdg Foreme this
/j�D_�daa�yof -VUr6l ,20.20 by-
4 who is eersonally kno to
meorwhoh produced as lD.
72`0 A � l-/O-.2Z)
signatumor Notary Date
pr Notary Pablie Slate OF Florida,
r° �o'c. Viclor G Altedzio
y My Commission GG 274292 /
RRR �p E;Ores I tIC52e22
?ciao