HomeMy WebLinkAboutChange of ContractorPLANNING & 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 mast 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: LQ - a3- tea.- J,
Permit Number: a 1 r)a - OkAq:�
Site Address: Su' a St �yQ_r 00a- Z)\r*\y2J
�C_V,State License I'C I' 19VSe SLC License aclqqq
Original GC, subcontractor or owner/builder
G-E —a�L ic-1-e C_-� �C--_., State License E_� 1301539 8 SLC License 3 19
New GC, subcontractor
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold liarmless�t 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 c ncelled if work hmbeen performed.
SIGNATURE OF OWNER (or owner/builder) SIG TURF GENERAL NTRAC" R (or new GC, as applicable)
PRINT NAME PRINT NAME Sok
State of Florida, County of St. Lucie County State of Florida, County of St. Lucie County
The following instrument was acknowledged before nme this The following instrument was acknowledged before nme this
day of , 20_, by d, '�, day of _, 20 Z-t , by :S�
who is personally known to nmc
or who has produced as ID.
Signature of Notary Date
Revised 04/15/16
who ' personally know to
nme or who has produced as ID.
-J — CP - a3-a0-z)k
Signature'bf Notary C3 Date
S Kelly Finley
Notary Public
CV State of Florida
Comm# HHOS2506
Expires 1/19/2025
PERMIT # ISSUE DATE 1 ::1
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PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
ei c- I hate agreed to be
(Company Name/Individual Name)
the (✓ (n o,-�Y ic_ Sub -contractor for C uil���S i�►c,
(Type of Trade) (Primary Contractor)
For the project located at SUba. '5;tJQx- 0CL_y. 6'iO-C,
(Project Street Address 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.
/J/ / d7�
C RACTOR SIG. • Quaimer) SU CONTRAC. OR SIGNATURE (Qualifier)
PRINT NAME
I LQI:�'1`l
COUNTY CERTIFICATION NUMBER
State of Florida, County -of k • l.� �.� R '
The foregoing instrument was signed before me this day of
20?-t , by V-rc2_-o—
who "s crsonally kno« or has produced a
as identification.
STANI P
Signature of tar- Public
Print Name a4 Notary Pub .
��lAR a Kelly Finley
Notary Public
o , oState of Florida
Revised 11,1162016 2 a Comm# HH082506
�' Expires 1/19/2025
oG, rn �r ca -7- 8 (Y_k o
PRINT NANIF
3 O(A g
COUNTY CERTIFICATION NUMBER
State of Florida, County of S'-• 1 ��
The foregoing instrument was signed before me this zZ3 day of
'$_y van- , 20 Zl, by 5`6, G0.2-4c (-0
who produced a
as Identification.
STANIP
Signature of N to Public
Print Name of Notdry Public
� A_ 44 Kelly Finley
Notary Public
—State of Florida
Comm# HH082506
sxHCE I'S Expires 1/19/2025