HomeMy WebLinkAboutchange of contractorCOUNT
F L
0 R I
D A
PLANNING & DEVELOPMENT
BUILDING & ZONING DIVISIO]
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR — Change of Contractor is to be signed ,
and the new contractor of record for the current permit. A new permit application
contractor information and signature. A new Notice of Commencement must be
for job values greater than $2,500 ($7,500 if A/C Change -out). A recorded
commencing any work. There is a $50.00 fee for the Change of Contractor.
CHANGE OF SUBCONTRACTOR — Subcontractor changes are to be c
The new subcontractor must fill out a Subcontractor Agreement Form. There is a
Contractor.
-13 E11- CANCELLATION OF PERMIT — The cancellation of a permit is accep
Cancellation of permit is to be signed and notarized by both the owner and qua]
cancellation of the permit.
Date: 09/14/2021 Permit Number:
Site Address: 6513 Emerson Ave
State
Original GC, subcontractor or owner/builder
C H(J(20 State
New GC, s contract
Vs�
VICES
PERMT
id notarized by the property owner,
must also be completed with new
iled in the new contractor's name
,opy must be submitted prior to
;d by the general contractor.
fee for the Change of Sub -
only if no work has been done.
of record. There is no fee for
2108-0112
License
License
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 OWNER (or owner/builder); ` S A NERAL CON TOR (or new GC, as applicable)
PRINT NAME ' ,i w "V n' PRINT NAME
}h/
State of Florida, County of St. Lucie County State of Florida, County of St. Lucie County
The follolQg instrument was acknowledged before me this The following instrument was acknowledged before me this
_4 div of 20 `by �/ �il� Lday of `�W 20 2 � by
p who is personally known to me who is personally known to
0 o has ed �t 0 �� as ID. me or w o as oduced 1Q as ID.
09/14/2021 09/14/2021
Signa re o Notary Date Si atur of Notary Date
Revised 0&/15/16
All APPLICABLE INFO MUST BE COMPLETED FOR APPLICATION TO BE ACCEPTED
Date:
Permit Number:
U Building Permit Applicati n
Planning and Development Services
Building and Code Regulation Division Commercial Residential
2300 Virginia Avenue, Fort Pierce FL 34982
Phone: (772) 462-1553 Fax: (772) 462-1578
PERMIT APPLICATION FOR: ,2-(-00- P-
PROPOSED IMPROVEMENT LOCATION:
Address:
Property Tax ID #: t✓� — i�,� �� - %�� !
Site Plan Name:
Project Name:
Lot No.
Block No.
DETAILED DESCRIPTION OF WORK:
- T C�- �
New Electrical Meter Second Electrical Meter
CONSTRUCTION INFORMATION:
Additional work to be performed under this permit -check all that apply:
_Mechanical _ Gas Tank —Gas Piping _ Shutters _
Electric _ Plumbing _ Sprinklers _ Generator
Total Sq. Ft of Construction: Sq. Ft. of First Floor:
Windows/Doors _ Pond
Y Roof /2, Pitch
Cost of Construction: $ -CIO Utilities: —Sewer _Septic Building Height:
OWNER/LESSEE:
CONTRACTOR:
Name C
�,o iA I
Name:
Company: 1 Gtf:as)
Address: el- (-0)
City:
Zip Code: ��Cq-3
PhoneNo
E-Mail
State or County License)
Address: lQ - 191
I o �n
_
City: f�I_ {�-eaz State FC
Zip Code: �401 S ( Fax:
Phone No. 415--6L ?"2-4
E-Mail:
State
Fax:
Fill in fee simple Title Holder on next page (if different
from the Owner listed above)
�L- 22 171
If value of construction is 2500 or more, a RECORDED Notice of Commencement is reqL
If value of HAVC is $7,500 or more, a RECORDED Notice of Commencement is required.
SUPPLEMENTAL CONSTRUCTION LIEN LAW INFORMATION:'
DESIGNER/ENGINEER: _ Not Applicable
Name:
MORTGAGE COMPANY:
Name:
Address:
City:
Zip: Phone:
Not Applicable
Address:
City: State:
Zip: Phone
State:
FEE SIMPLE TITLE HOLDER: _ Not Applicable
Name:
BONDING COMPANY
Name:
Address:
City:
Zip: Phon
Not Applicable
Address:
City:
Zip: Phone:
OWNER/ CONTRACTOR AFFIDVIT: Application is hereby made to obtain a permit to do the work and installation as indicated.
I certify that no work or installation has commenced prior to the issuance of a permit.
St. Lucie County makes no representation that is granting a permit will authorize the permit holder to build the subject structure
which conflicts with any applicable Homeowners Association rules, bylaws or and covenants that may restrict or prohibit such
structure. Please consult with your Homeowners Association and review your deed for any restrictions which may apply.
In consideration of the granting of this requested permit, I do hereby agree that I will, in all re�pects, perform the work
in accordance with the approved plans, the Florida Building Codes and St. Lucie County Amendments.
The following building permit applications are exempt from undergoing a full concurrency review: room additions,
accessory structures, swimming pools, fences, walls, signs, screen rooms and accessory uses tb another non-residential use
WARNING TO OWNER: Your failure to Record a Notice of Commencement may result in paying twice for
improvements to your property. A Notice of Commencement must be recorded in the public records of St.
Lucie County and posted on the jobsite before the first inspection. If you intend to obtain financing, consult
with lands-r or an attornev before commencine work or recordine vour Notice of Commencement.
-�&W/
SiCaZure of 0
fflame
er/ Lessee/Contra r as Agent for Owner
STATE OF FLORIDA
C—
COUNTY OF
Sworn to (or affirmed) ano subscribed before me of
this (4 day of 201 by
Physical Presence or
Online Notarization
//
Name of pe s n
king statement.
Personally Kno
n OR Produced Identification
Type of I entific
n Produced L l y�Slz
(Sig a
Public- State of Florida)
0 pR s Kenny Henzow
Commission No.
(Seal)
Notary Public
o _, 'State of Florida
Comm# HHOS7667
NEE i'= Expires 2/1/2025
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Rev 5/ZU/21