HomeMy WebLinkAboutPizzi Permit Cancellation FormPLANNING & 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-
Contr or.
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: . b - & 1 Permit Number: 4- 11 C) — n
Site Address:
�I Czar r . Po�-�- ' e_ 3y�i2
VA Stat censeC 6 nse
Original GC, subcontractor or owner/builder
State License SLC License
New GC, subcontractor
Reason for Cancellation
#Jc._) �cxtc _� 1aeert ��
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers, agents and employees from all
costs, fees or da rising from any and all claims of action for any reason, which may arise as a result of this change of
ontractor/su trac r or cancellation of permit. A permit cannot be cancelled if w rk has been performed.
GNATU O' ER (or er/builder) SIGNATURE GENERAL C TRACTOR (or new GC, as applicable)
PRINT NAME tO%U�
PRINT NAME Ti k P uJ
State of Florida, County of St. Lucie County
State of Florida, County of St. Lucie County
The 191lowing instrument was acknowledged before me this llowing trum t was acknowledged before me this
day of� , 20 e2(, by� day of , 20AAby
who is personally known to me who i ersona ly kno to
�whoroduced �D • as ID. r who has produce as 1D.
10-I — f6 Y' Z(
Signature of Notary Date ��— Signature of Notary Date
KONNI LENAE DEWITT
Notary Public • State of Florida
Revised 04/15/16 =, e Commission # HH 165134 Y'P� KONNI LENAE DEWITT
My Comm. Expires Dec 10, 2025
. o��,d?:� f�G��: Notary Public •State of Florida
9onded through National ."rotary Assn. � ;= Commission # HH 165134
F° ' MY Comm. Expires Dec 10, 2025
.., Bonded through National Notary Assn.