HomeMy WebLinkAboutGreen Cancellation§ r.5, 0?`Q YA111Y
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.
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: 1 a a s —6)0 Permit Number:
Site Address:p�-
State License SLC License
Original GC, subcontractor or owner/builder
State License SLC License
New GC, subcontractor
Reason for Cancellation boo c,5 came- ( ) a K Q
The undersigned does hereby agree to indemnify and hold harmless St Lucie ounty, 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 cancellatio of permit. A permit cannot be cancelled if work has been performed.
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SIGNATURE OF OWNER(or owner/builder) SIG NE`RAL CONTRACTOR (or new GC,C as applicable)
PRINT NAME 411 1*-S O YI A r-4P-P h PRINT NAMES
State of Florida, County of State of Florida, County of St. Lucie County
The following instrument was acknowledged efore me this
day off_, 20, byY)
sir e to who is personally kn� o`�e
or who h roduced & 49, L. as ID.
Signatur of NoW4 Date
PRv r,q n ANGELAYOUNG
a Comm scion # GG 968864
Revised 09/15/1f Expires April12,2024
9jC �`�oQJ Banded I hru Budget Notary Servioes
OF FL
The following instrument was dcknowledge4 before me this
--ip_day of - i an - - 2(,(, by JAmPS D.
AGV1 J who is personally known to
mgor "99. produced as ID.
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Signet a of No ry Date
`�tPRV pUe/
ANGELA YOUNG
Commission # GG 968C64
ExpiresApriJ
o�
OF
12, 2024
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Bonded r11u Budget Notary gervt.-s