HomeMy WebLinkAboutSLC Permit Cancellation Form - Goetzinger� d 2300 VIRGEWA AVE
�' - �.. aray, '-. is o . •.. ad:: �. _
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACT9113 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 ofrecord 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 midst 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: Ll �� L
Permit Number: 2101-0585
Site Address: x 1419 -u C cccn l%t .Y1 Vitf6t -L -
A GREAT FENCE State License CGC-1527571 SLC License
Onginai GC, subcontractor or owner/builder
License SLC License
New GC, subcontractor
Reason for Cancellation going a different direction with property, no longer installing fence.
The undersigned does hereby agree to indemnifyr and hold harmless St Lucie County, its officers, agents and employees from all
costs, fees or damages arising from an and all claims of action for any reason, which may arise as a result of this change of
contractor/subcontractor or carrell 'on ermiL A permit cannot be elfed if work has been ed.
S [MATURE OF OWNER owner/bu, } SIGNATURE GENERAL CONTRA R (dr new GC, as applicable)
PRINT N PRINTI�IAME Darrick B i .y
It �c �
State of Florida, County of st. tMie County �• State of Florida, Comty of st Lucie County
The following instnunem was acimowfodged before me this
`day oft y 20---�L byy',C Z -
e' AA . who is personally brown to me
tore of Notary Date � � �p�
Revised 04/15/15 ��+P�`®G: MEIYNBAILER SOSEPH
? ` Notary Public - State o. Florida
-� •' 4: Commission g GG 247597
.cL5 My Comm. Expires Aug 9, 2t122
1119 following a Ras ac3mmviedg before me this
/day of )2i'�•+." 20� by
isX40nally ]mown to s
m7el Uilo has pro red t as-1 _
7-0 J
s• c of Notary Date
�Notary Public State of Florid&
; Crystal E Nayion
My Commission GG 929$48
Facprres 111OWD23