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HomeMy WebLinkAboutChange of ContractorLANNING &DEVELOPMENT SERVICE
BUIIrDING &ZONING DIVISION
17
2300 VIRGINIA AVE
FORT PIERCE; FL 34982
(772) .462-1553 FAX 462-1578
JUN 12 201
PERIMI1171NQ
St. Lucie County, FL
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 signed by the general contractor only.
The new subcontractor must fill out a Subcontractor Agreement Form which is signed by both the contractor and
subcontractor. 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:
Permit Number: 1 n - c L
Site Address:. 153 J � f oin 6i1 V t�f V`2
�ri' kl - State License SLC License _
rigmal GC subcontractor or owner uilder
GO State License 1C ls0 SLC License
New GC, subcontractor or owner uilder
Reason for Cancellation
Tile undersigned does hereby agree to indemnify and hold harmless St Lucie
costs, fees or damages arising from any and all claims of action for any reKo
contractor/subcontractor:or cancellation of permit. A permit cannot be Banc
Z 4_��
Imo`
S ATURE OF'OwNER (or owner/builder)
%% •SIGNATURE d
PRINT NAME��j^l/1O �,°t PRINTNAMEF
State of Florida, County of St. Lucie County
officers, agents and employees from all
ry arise q a result of this, change of
MMZ7d.�
(or new G9, as
State of Florida, County of St. Lucie County
The following ' eat was acknowledged before me this Thefqllowig instrument was ac ledg before me thi
day of. 2011 byL� e�Ko(iS �Y of y 20 by� fl��
who is personally known to me c who is personally known to
or who has producedLL L as ID. me or who asp r3uled as ID.
Signature of Notary Date Signature of Notary Date
E
KAREN S. :FF
LSENPAMELACORTESot•CommissionS b5537Revised 05/18/2017 :2,�i`S:: NotaryPubllr-State of Florida *;CoyPublionkG6080lorida+My Commissixpires' 0My Comm. Expires Apr30,2021 iUnB 121'8
OPF °e' Bonded through National NotaryAssn.
• 0
PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
o
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: ©3— Z 7 — gw/d'
Permit Number: 1703 " O 51f /
Site Address: 1 S3,S-51 N,4111,9 1 D%/!_E
AJie J%�WO 7- State License GACfcPlVIVaSLC License ZS'_j63
Original GC, subcontractor or owner/builder
X.4z- Afire State License eCO ,SB467.SSLC License
New GC, subcontractor
Reason for Cancellation 7P 1-4S9- /%/1r-4tA#7_ t-fad 4�V7Xd, - 7-0,4--
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
contragtor/subcontractor or cancellation of permit. A permit cannot be ne ed j f^*rk has been performed.
SIG14ATVRE OF OWNER�br i�,23e owner/builder) SIGNATURE GENERAL CONTRACTOR (or new GC, as applicable)
PRINT NAME ZA;;;,il�s PRINT NAME_ D�'r/ (�Q(47%%zp
State of Florida, County of St. Lucie County
The following instnunent was acknowledged before me this
-!!day of itf H , 20A, by
kMYASIVW who is personally known to me
i-
orwho has >r, d as ID.
&)re of Notary Date Ryan Seals Slattery
NOTARY PUBLIC
Revised 04/15/16 STATE OF FLORIDA
01"Comm# FF194445
Expires 1/29/2019
State of Florida, County of St. Lucie County
The following ins ,�,ent was aclmgwledged before me this
day of M*K14 20 0 by
6"We &a*154dwho is personal1 wn to
me or who has rod r ed as ID.
3 z� is
Si to of Notary Date
t Ryan Sean Slattery
NOTARY PUBLIC
STATE OF FLORIDA
e= Comm# FF194445
Expires 1/29/2019
PERMIT # ISSUE DATE
PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
BIJTI.D.I.NG PERMIT
SUB -CONTRACTOR AGRI?TEMENT
r
/ �7F�L _ �} 14 -,� 11C • have agreed to be
(Company Nameitnd'vJ ital Name)
the ............._.__._ � .._.... _-.._....._........._...................__.......- —... Sub -contractor for - .....G
(Type of Trade) (Primary Contractor)
For the project located at. ,�%T��1/S' /�rj � Al/gL/D/Il r��
-.. -- _......._._....
(Project Street Address or.Property Tax ID 4)
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.
CO`,RACTOR SIGNATURE (Qualifier)
PRINT N4YE
1"'wC/50'a? p / 3 o/ po
COUNTY CI?RTIFICATION : IJIMBF.R
State of Florida, County of
The foregoing instrument was signed before me this vy of
A ff 2& by G'iP. /„Ofl1 �1y0
who is personally known or has produced a
as identirication.
_ 3/27 �t% STAMP
Silktatur vF Notary Public
�W 5t.017vIw
Print Name of Notary Public Ryan Sean Slattery
NOTARY PUBLIC
'STATE OF FLORIDA
Comm# FF194445
6 te'►� Expires 1/29/2019
Revised 11116,12016
G
_........-....__.........._......................... _.....
_.. --
SUB-C 7Rr TOR SIGNATLIRI (Qualifier)
PRINNT NANIE
r$;1?J01/
COUNTY CERTIFICATION NU iBER
State of Florida, County of 5T Lu cK
The foregoing instrument was signed before me this 6 day of
rn� 20aby PQdJfa(&
w s persona _ nutvn _or has produced a
STAMP
NORMAJ.STACK
-i MY COMMISSION # GG 060347
IF P� EXPIRES; Ma 5 2021
60nded Thnt Notary Pubric Unde-Wdtcrs