HomeMy WebLinkAboutChange of ContractorPLANNING & 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 PERNIT
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
com_ ep m�`ing 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 PERNUT — 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:
Site Address: , q (0-1 & u
Permit Number: a Ob (0 — 06
0+" 1 �P
N-e_C-V V✓l(_\ (C JQ \ )I1 State LicenseCAOce,8)?1SLC License
Original GC, subcontractor or owner/builder / ,^Q (`(� p
State License CA 07��SWLC Licensee '�JO
New GC, subcontractor
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers, agents and employees from all
costs, fees or d agespsing fre any and all claims of action for any reason, which may arise as a result of this change of
contractor/su tr for or c t6ellaC of permit. A permit cannot be cancelledy work has been performed.
SIGNA^ OF(OW N v(or oowneerr/buildert)y1-f� SIGNATURE GENERAL CONTRACTOR (or new
/GC, w applicable)
PR T NMEI O C.\ `yl)V� (3A PRINT NAME eGitc.^� /YIniJT"
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 following instrument was acknowledg efore me thi
a'Jday of_ nP.� ,20,,Q, by r4 W1K -�. -day of 0-et""20 1)by
M a4 TF41 TO who is personally known to me who i personally (mown to
or who roduced as ID
or or who has produced as 11).
�Ck-LrA IaIA11Mo I�9,,,,_1`1j3mCrean t�a�i�2o�c�
Signature of Notary Date Signature of Notary Date
Notary Pubic State of Florida
Revised 09 /15/16 ?� Robin L Bowen .J' Notary Public Sores of Florida
My Cortm"on GG 298212 f fO Robin Bowen
qa � Expres 02/WR023 +� F My Commission GG 298212
Yd; Ezp ors 02104r2023
GCCel . ')'4ky S(Jl- lMzraoojo
PERMIT# �%/�(�(� CC �a ISSUE DATE
PLAANNIN�-G�&tIDEVELOPMENT SERVICES
- = Building & Code Compliance Division
COUNTY.
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
have agreed to be
the Sub -contractor for TS L -Rif C) er-- I es k 0 c
(Type of Trade) (Primary Contractor)
For the project located at -ILA GLI
(Proiect Street Address or Pr
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.
CONTWiCTOR SIGNAT (Qualifier)
Max k M0 n�a l-ta
PRINT NAME
31220
COUNTY CERTIFICATION NUMBER
State of Florida, County ofa lUu lit
The foregoing instrument was signed before me this � day of
Dp(- 20_jLbby WJ%Vr_ ff)(�aTW17fl
who is personally known Y or has produced a
SUB -CONTRACTOR SIGNATURE (Qualifier)
N chard Nu.O
PRINT NAME
�;) 0-a�s03s
COUNTY CERTIFICATION NUMBER
State of Florida, County of a,& L auc 'e
The foregoing instrument was signed before me this 6& day of
11WC 20_20by 1c.h. V-,J Huy)7
who is personally known X_or bas produced a
as identification. 1 (\'�� g� 1 , ,. �I ,, as identification.
PA �(Y. A) I 1 lL r ti I A NI P ]� STAMP
Sig Lure of Notary Public Sigiiatu& of Notary Public
NPublic� PrintName of Notary PublicP nmbomrary� 2-vs ,e_o n V, ow evV
�o' 0 Notary PUNIC State of Flw,d
Robin L Gowen t pia Notary PadIC Stale of Flond,
+� My Commission GG 2ae212 Robin L Bowen '
4a w� E.pires 02/Oa2023 My Commission GG 2aa212
Revised 11/16/2016 �trw� Ecpirea 07/002023