HomeMy WebLinkAboutChange of Contractor PLANNING 6& DEVELOPMENT SERVICES
- BUILDING & ZONING DIVISION
' 2300 VIRGINIA AVE
r r
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
CHANGE OF CONTRACTOR,SUBCONTRACTOR'OR CANCELLATION OF PERIViT
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 PERART-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:
Site Address:_SJ .- vi�S� Q --_�`• - �Y� P`�Y(��
�-RI&n pl &ta -zn • " State LicenseV_VT.®1C10'1P7 SLC License
Origii l GC, subcontractor or o er/builder
nJ�1in Dre W,s ejumbi State License C.9114Z9 L{S LC License
New GC,subcontractor .J
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
co trr� actor/subcontractor or cancellation of permit.A permit cannot be cancelled r hha en performed.
S G) NXTURB OF OWNER(or owner/builder) SIGNATURE G NE CONTRACTOR(or new GC,as applicable)
PRINT NAME/%,/, any p,�.`. ( yl�- PRINT NAME
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following instrument was acknowledged before me this The lowing instrument was acknowledged before me this
2 'z"day of ir;` ,202-1 ,by
's who is personally known to me 4►rye orn- who is personally known to
or wh as produced as ID. me or who h produced as ID
q IU12-1 '-I 12-wh02-i
Signature of Notary Date Signature of Notary Date
. .
rf ANGIEPERDOMO YF0, ANGIEPERDOMO
Revis �1�Iotary Public.State of Florida Notary Public•State of Florida
Commission#HH 47988 z. ®Qd Commission#HH 47988
oe� My Comm.Expires Sep 29,2024 ort� V My Comm.Expires Sep 29,2024
Bonded through National Notary Assn. Bonded through National Notary Assn.
PERMIT# 2 � �3-- d 3 Z ISSUE DATE
;,v i PLANNING & DEVELOPMENT SERVICES
VICES
- Building & Code Compliance Division
'COUNTY
BUILDING PERMIT
SUB-CONTRACTOR AGREEMENT
L�l Uf W"f> lJl ��6 4- `C_� have agreed to be
(Company Name/Individual Name)
the I�LVi(l� Sub-contractor for PGLPJ
(Type of Trade) (Primary Contractor)
For the project located at�ZLPLV Vespefol `. :0rN- P
(Project Street Address or PYoperty 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
-C,OQNTRACTO ATUoR�E(Qualifier)
4 gg
PRINT NA11W PRINT NAME
COUNTY CERTIFICATION NUMBER COUNTY CERTIFICATION NUMBER
State of Florida,County of State of Florida,County of c�� •l�lJlGl�,
The foregoing instrument was signed before me this W -'da/yof��,,�� The foregoing in _instrument was signed before me this day of
20Z_.� by�_q" an t���l olykS JN t/*1 ,207.1,by IMOOL
i�r• �E tre�enh
who is personally known or has produced a who is personally known !/or has produced a
as identification. as identification. ,�a;Y"au ANGIE PERDOMO
�;jPv'., ANGIE PERDOMO �. Si Notary Public•State oaa
� tary PubIftT,3Ii�of Florida ofCammissiog��1�41¢�Signature o Notary Public �% Commission li HH 47988 Signature of Notary Public .o! omm.Expires Sep vrti�� My Comm.Expires Sep 29,2024 Bonded through National Not
y� Banded through National Notary Assn. kn[ 'e � � ®
Print Name o otary Public Print Na nN ofot
m Notary Public
t
Revised 11/16/2016