HomeMy WebLinkAbout2306 s 39th st_Cancellation requestPLANNING & 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.
iT�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: 5128121
Permit Number: 2103-0498
Site Address, 22K .P S S94Nl S�, C�� �I �.r �`L . r" E S`1 1
RICHARD BASSOFF
Original GC, subcontractor or owner/builder
State License CFC1426115 SLC License
State License SLC license
New GC, subcontractor
Reason for Cancellation This was to be under the master permit 1910-0065- was not supposed to be a standalone pen -nit
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 /subcontractor or c cellation of permit. A permit cannot be c d ' work been performed.
SIGNATURE OF O ownerlbuilder) SIGNATURE GENER C ACTOR (or new GC, as applicable)
PRINT NAME9\CkoyrC� �O` S PRINT NAME RICHARD BASSOFF
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this _�r�(-'
28 day of MAY 20 2 1, by (_J agsd �'
or
who is personally known to me
as ID.
5/28121
Date
Revised T�-
Notary Public State of FloridaJacqueline Georgescu
yctjMY Comrnlss,on GG 233150
Expires06J2&2022
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
z8 day of MAY 2021 by 2cruRoen -,
RICHARD BASSOFF
who is personally known to
_as 1D.
5128/21
of Wot& Date
40 ,gyp Public Public State of Florida
Jacqueline Georgescu
MY Conxnisa GG 23315o
O/ R Expires 08128/2022