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PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
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.
X 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$50.00 fee for the Change of Sub-
Contractor.
""°0 CANCELLATION OF PERMIT—The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: 4110 2929 Permit Number: 2992-0741
Site Address.
33 NOGALES WAY
LAW$ELECTRIC,INC. State License SLC License 2090
Original GC,subcontractor or owner/builder
FLORIDA STATE ELECTRIC,INC. State License SLC License 27207
New GC,subcontractor
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and loyees from all
costs,fees or damages arising from any and all claims of action for any reason,which may aris a resu o is change of
contractor/subcontracto ncellation of permit.A permit cannot be c if wo bee p ed.
SIGNATURE OF OWNER(or owner/builder) SIGNATURE GENERAL CONTRACTOR(or new GC,as applicable)
PRINT NAME MATTHEW LYLE WYNNE PRINT NAME ALAN WALTON
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 f`olIpwing instrument was acknowledged before me this
MgTTHEW LYLEYNNE �(e'day of 4PRIL .20 0 ^ MUON
1�day of L 20 cR by /
who is personally known tome Y who is personally known to
or who has produ d as ID. or who h pro ced as ID.
1612020 •4/16/2020
Signature otary Date Signature o otary Date
WMQ&1'• DOROTHYANN BASKIN +�`=S=�°' �7;; ^DOROTHYANN BASKIN
"`' Vic MY COMMISSION#GG 030145
Revised 04/15/16 MY COMMISSION#GG030145 =+'
z;;'• o�F EXPIRES;October 2,2020 <, 'd�F EXPIRES;October 2,2020
.Fox F;�a'•• Bonded Thru Notary Public Underwriters ire^{, �ii�� ®DOW Thri Notary Public Underwriters
PERMIT# 2002-0741 ISSUE DATE
, F PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
COUNTY
Y •
BUILDING PERMIT
SUB'CONTRACTOR AGREEMENT
FLORIDA STATE ELECTRIC, INC. have agreed to be
(Company Name/Individual Name)
the ELECTRIC Sub-contractor for WYNNE BUILDING CORP.
(Type of Trade) (Primary Contractor)
For the project located at 33 NOGALES WAY
(Project Street Address or Property Tax ID#)
It is understood that, if there is any change of status regarding our participation with the above mentioned
project,the Building and Code Regulation Division of St. Lucie County will be advised pursuant to the
filing of a Change of Sub-contractor notice.
CONTRACTOR SIGNAT (Qualifier) SUB-CONTRACTOR GNATURE(Qua> er)
MA17HEW LYLE WYNNE ALAN WALTON
PRINT NAME PRINT NAME
08898 27267
COUNTY CERTIFICATION NUMBER COUNTY CERTIFICATION NUMBER
State of Florida,County of ST. LUCIE State of Florida,County of ST. LUCIE
The foregoing instrument was signed before me this Z"day of The foregoing instrument was signed before me this day of
it: 20&_�Qby MATTHEW LYLE WYNNE amli. 20 ,�qby ALAN WALTON
who is personally known Zor has produced a who is personally known✓r has produced a
as identification. D as identification.
STAMP STAMP
Signature of Not,
ot Public Signature of Notar iblic
V*1_bcti,9 07'H y /q-r+N \
AASAr/r' � )0R07KY ANn) lU�4S�lIJ
Print Name of Notary Public Prmt Name of Notary Public
"'O" DOROTHYANNBASKIN
DOROTHY ANN Br1SKIN �;q'411'' SSION#GG 030145
MY COMMISSION#GG 030145 pr MY COMMI
EXPIRES:October 2,2020 ?s ,$� EXPIRES;October 2,2020
Public Underwriters F �` Bonded Thtu Notary Public UndervrritCrs
Revised 11/16/201
,, ,�, BonWThruNotary ,