HomeMy WebLinkAboutChange of sub, HVAC cvq '
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.
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: e2_1 2D W Permit Number: IZ-0 SD 4
Site Address• ",' Ida
Y 1� �• l r• State License .01(om__C License
,,(Original GC,
11 subcontractor or owner/builder /nj(n1. „ qr cy
r"11 r l�n d 1��d State LicenseeIll, 3� 86 SLC License ,Z '2(��?Do
New GC,subcontractor ,^
Reason for Cancellation Y)0 1®n qgr uS i ' :FA �'eC r ►• 1 r
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agents and employees from all
costs,fees or damages arisitce
eoit.
ms of action for any reason,which may arise as a result of this change of
contractor/subcontractor oA permit cannot be cancelled if/or/k has been performed.
SIGNATURE OF O R(or owner alder) SIGNATURE GENERAL CONTRACTOR(or new GC,asa{p-plicable)
PRINT NAME Max � mofy�a({ PRINTNAME�ICrr `��6 �U.A 1 .
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following instrument was acknowledged before me this Tye ffllowing instrument was acknowledged before me this
p�Z N day of 3e P 20 jb ,by fo Pr /fit• day of c5Q Pr ,20A6,by ��_
{/1 Ila I f-(� who s persona y known to me 4 ylr\T who ersonal own to
i
or Mhas oduced as ID. me or who has produced as ID.
9 ADa0 �c�,,,,� 11 �j��4
Si a re of Notary Date Signature of Notary Date
Revised 0 4/15/16 �.Oyv Notary Public State o1 Florida Notary Public State of Florida
Robin L Bowen Robin L Bowen
< My Commission GG 298212 My Commission GG 298212
aid Expires 02/04/2023q Expires02/04/2023
PERMIT# �Q r� 2 —O�V y ISSUE DATE
. ,_7
,� ;PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
COUNTY
BUILDING PERMIT III
SUB-CONTRACTOR AGREEMENT
Air Cnr)&'760n't-n a U have agreed to be
(Company Name/Individual Name) 1 ,
the Sub-contractor for T S L � '( O p e'+r 1"1 es �n C.
(Type of Trade) (Primary Contractor)
For the project located at
(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 Cthange of Sub-contractor notice.
CONTRACTOR SIGNAT (Qualifier) SUB-CONTRACTOR SIGNATURE(Qualifier)
PRINT NAME PRINT NAME
31220 ao-a�so38 �gga2
COUNTY CERTIFICATION NUMBER COUNTY CERTIFICATION 1 NUMBER
State of Florida,County of S+ 1..lucAt State of Florida,County of�-7�•t-t� c `Q The foregoing instrument was signed before me this day of The foregoing instrument was signed before me`thiA*day of
c5PPS ,20 `Lby MAf\ .n'Y_ _M1m -��2� ,20c?D (
by i '`CRNf L' )VIT
who is personally known x or has produced a who is personally known_)(_or has produced a
as identification. as identification.
I
STAMP f� STAMP
Signature f Notary Public Signa*tare of Notary Public
2c'6` 1' �J l
Print Name of Notary Public i Print Name of Notary Public
�,1►" ERobinLBogw6n
of Florida Syr Notary Public State of Florida °
�. , + Robin L Bowen
F • G 298212 My Commission GG 298212Revised11/16/2016 ,,,�dF3 �a,F,d� Expires02/04/2023
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