HomeMy WebLinkAboutChange of Contractor 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.
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Date: LA 1 Z%,1 21012 ,1 Permit Number: oz -
Site Address•
. 3(110 l i, t1i- ,�- �"O+r� P i-e rCe . FL
Y State Licenstf _01 1011 SLC License
Original GC, subcontractor or owner uilder
.InJWr1r��Y� DYeAw �S LLMb:CV1 State License Jr J 4'0'[S'IOSLC 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
contractor/subcontractor or cancellation of permit.A permit cannot be cancelled if work has been performed.
SIGNATURE OF O, �y -(orowner/builder) SIGNATURE GENE CTOR(or new GC,as applicable)
PRINT NAME � PRINTNAME Ja�Yt�r �lr,nP eZ
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following instrument was acknowledged before me this a slowing iK strumerlt was acknowledged before me this
2,e-day of� 202 A 'by day of 1 20�,by l+n�n -sir.-e-r-'eZ
6!_� ALYI ]4CkQ_#VLZ who is personally known to me who is pecsonalls kno�n to
or who has produced
as ID. me or w o has produced as ID.
L4IZy 1-�L% tI IZO"L�
Signature of Notary Date Signature of Notary Date
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Y'�°G;: ANGIE:ee
M0
Revised 04/15/1617"
"Fad Notary Public ofFlori ANGIE PERDOMO o •" Commissio 47988` Notary Public•State of Florida f ' M Comm.Expires 29,2024- . Y PP
�A: Commission/t HH 47988 Bonded through Natotary Assn.
or c�;..• My Comm.Expires Sep 29,2024
Bonded through National Notary Assn.
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PERMIT# 21 C) 2-- D3 t l 9 ISSUE DATE
PLANNING & DEVELOPMENT SERVICES.
Building & Code Compliance Division
s '
- - - BUILDING PERMIT
SUB-CONTRACTOR AGREEMENT
I
Dr ,W tS P ( rD bt i( O z-v Dai n have agreed to be
(Company Name/Individual Name)
the P1 u,�(Y1 Sub-contractor for k[plG1xw s �N+nr-�reS
(Type of Trade) (Primary Contractor)
For the project located at SaLQD Lu Q c) S-1-fry - _ V:::DYA- P I-evC-P
(Project Street Addr s 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.
CONTRACTOR SIGNATURE(Qualifier) SUB-CON TORS TURE(Qualifier)
PRINT NAME PRINT NAME
COUNTY CERTIFICATION NUMBER COUNTY CERTIFICATION NUMBER
State of Florida,County of S�'•�lf,i_e_ State of Florida,County of � ►�
The foregoing instrument was signed before me this 23 day of The foregoing instrument was signed before me this ot'�day of
202.,1 byWa < (3YvIIi#'1 µ}dQrntS i zo?J,bbyy FXnJ�+r� �in�n�Z
who is personally known Z or has produced a who is personally known ✓ or has produced a
as identification, as identification. oa•,, ANGIE PERDOMO
Notary Public-State of Florida
.i►ar Po`:, ANGIE PEPMkfhp Comm§VKNg1WH 47988
Signature of Notary Public ublic-State of Flori a Signature of Notary Public y Comm.Expires Sep 29,2024
�•- ^ter
:•, Commission#HH 47988 Bonded through National Notary Assn.
'l x h . My Comm.Expires Sep 29,2024
Bonded through National Notary Assn. `P C(pt p IYZ
Print'Name of Notary Public Print Name of Chtary Public
Revised 11/16/2016
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