HomeMy WebLinkAboutChange of ContractorPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE RECEIVED
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
JAN 2 0 2021
Permitting Department
St, Lucie County
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: I ` z —2 / Permit Number: 2 -2
Site Address: 5-?oI NY t) P
CrU ora-AtR Ptt/041liKS 1 it/ i� State License SLC License
Original GC, subcontractor or owner/builder
VuAer 3o (der
State License SLC License
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 damages arising from any and all claims of action for any reason, which may arise as a result of this change of
contract subc tractor or cancellation of permit. A permit cannot be cancelled if work has been performed.
SId5ATURE OF OWNER ( r owner/builder) SIGNATURE GENERAL CONTRACTOR (or new GC, as applicable)
PRINT NAME '4. L JCiXQ--
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
b%O day of ZOVY-, 20_4�\_ by!5 + Jk S
Qi„ X � ?r, who is personally known to me
or who produ I L 1P as ID.
I AA `�-
Signature of Notary
KAREN S. NIELSEN
Bic State of Florida Notary Public
Commission # GG 207484
Revised 04/15/16 a; M Commission Expires
y June 12, 2022
PRINT
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.
Signature of Notary Date
PERMIT# 200q — 06Z-z ISSUE DATE S — i/t ZQ
PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division RECEIVED
dl?s Pk IOPP
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
Owner 130t I we r
JAN TO 2021
Permitting Department
St. Lucie County
have agreed to be
(Company ame/Individual Name)
the Pool t( PtS Sub -contractor for
(Type of Trade) U
[� (Primary Contractor)
For the project located at � GC� O / P41w ) i, '
(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 Change of Sub -contractor notice.
CONTIKCrOR SIGNATURE (Qualifier) SUB- ONT ACTOR 9fGNATURh (Qualifier)
('30A
.
PRINT NAM . It
COUNTY CERTIFICATION NUMBER
State of Florida, County of6-�. L%' �
a`
The foregoing instrument was signed before me this ) day of
who is personally known or has produced a
PRINT NAME
OQA
COUNTY CERTIPWATION NUMBER
State of Florida, County of S L C
The foregoing instrument was signed before me this °�d day of
S0\y1 , 20 al, by 6G \ e, S f In % \ ag,
who is personally known _or has produced a f L>Q L-
as identification. as identification.
STAMP TAMP
Sign. m o o ry Public Si na re of otary PubTic
KAREN S. NIELSEN
Print Name of Notary LZ a e o otary Public
*6 Commission # GG 207484
My Commission Expires
0i10�`�` June 12, 2022
Revised 11/16/2016
KAREN 4
Print N r WHIN
Commis
opt`: My C/.
JI
K
KAREN S. NIELSEN
tate of Florida -Notary Public
Commission # GG 207484
My Commission Expires
June 12, 2022