HomeMy WebLinkAboutCancellation 6699 Dickinson TerrPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
lLLa 1 112300 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.
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.
X 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: 11 /24/2020
Permit Number: 2-0 t k 0 1-( 6
Site Address: x t i 6 S Z /�r r• � i_ 3 `/ C�
ONE CONSTRUCTION & ROOFING State License CCC1330623 SLC License
Original GC, subcontractor or owneribuilder
License SLC License
New GC, subcontractor
Reason for Cancellation OWNER NOT READY
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 or cancellation of permit. A permit cannot be cancelled if work has been performed.
SIGNATURE OF OWNER or owner/builder) SIGNATURE GENERAL CONTRACTOR (or new GC, as applicable)
PRINT NAME MAURICIO ORELLANA PRINT NAME
State of Florida, County of St. Lucie County
The following instrument was acknowledged efore me this
2dayof� d�J 202L�,byG`n`t`li
Revised
2 •2 #GG 926545
�o� ?
9Plo y� eUnde
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of , 20_, by
who is personally known to
me or who has produced as ID.
11/24/2020
Signature of Notary Date