HomeMy WebLinkAboutChange of Contractor Apr 27 17 12:21 p Energized Gas 7728773614 P.1
PLANNING&DEVELOPMENT SERVICES
BUILDING&ZONING DIVISION
ICOUNTY
iF LORI DA -4460 2300 VIRGINIA AVE
FORT PIERCE,,FL 34982
(772)462-1553 FAX 462-1578
CHANGE OF CQN--TRACTQRSU1BC0NMA,,CT0R 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 Cbange-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-
Can coon.
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: LAI M/11
Permit Number: 7t�-�
Site Address: q"'M) C)ffrntxii9Y'
A.&I I B\ WLd &—A State Licensef�T, SLC License
Original GC,gubcontrattor or owHer/builder
State License SLC License
New GC,subcontractor
Reason for Cancellation 46
cs,
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,its officers,agent'and employees from all
costs,fees or damages arising from any and all claims of action for any 9 , 'ch may arise as aresult of this change of
contractorlsubcontractor or cancellation of permit.A permit cannot b c r een peiTormed.
SIGNATURE OF OWNER(or owncribuilder) SIGNATURE GENERAL CONTRACTOR(or neir CC,as applicable)
r,2-
PRINT YJAM ?RINTNAME ,I
State of Florida,County of St Lucie county State 001064 CMMt)r Of SL Lucie county
The following instrument was acicoo-ledged before me this Mitym, g, 1edJ=bqfbf6met
d OqV=20 ac� tV,.4L_I
_day of _.20__�by th
who is personally kao%n to me who is pwooalLy lqaown to
orwhobasproduced as ID. e oh produced as Ia.
111 AIM
signature of Notary Date
plowh Notary Public state of plame
Antonia M Paula
My Commiazion FF 1912011
Revised 04115/16
ExPltes 0212maiq