HomeMy WebLinkAboutformboardPLANNING & 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 ($71500 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.
Date:
Site Address: 3? a�; _F+U-R;\I-
Permit Number: a?=_ J 1 S:
G ka s c- LG reef S ery i r,Pi State License C CCll �� ag SLC License
Original GC, subcontractor or owner/builder
U�A LAtnerdl GCXlkW� 4?,00tra(�tateLicense CGCN".1IeSLCLicense
New GC, subcontractor
Reason for 2, Ic nu -
The
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers, agents and employees fror
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 b�if wo • as been performed.
O
SIGNATURE OF OWNER (or owner/builder) SIGN R�L CONTRACTOR (or new GC, as applicable)
C^1 PRINT NAME PRINTNAME Py),P KV_ J'�
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of 20_, by
or who has produced_
Signature of Notary
Revised 04/15/16
is personally known to me
as ID.
Date
State of Florida, County of St. Lucie County
The (plowing instrument �(as ac owledge before me this
_day of 1.1L1(AlSt , 20 1 by
(1 ti o is personally kno to
me or h tas s
Sie_ ai� al
na ur of 'ota v Date
TIFFANY RENEE DENTON
MY COMMISSION # GG 243842
EXPIRES: July 31, 2022
Bonded Thin Notary Public Underwrite