HomeMy WebLinkAboutSLC2104-0205 - Permit CancellationCOUNTY
F.
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PLANNING & 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.
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: %/fx /-2 J
Permit Number: 5Z C-
Site Address: ���s� /, �,Z 1-2?�✓ 16�/
State License�"3 SLC License
Original GC, subcontractor or owner/builder
License SLC License
New GC, subcontractor
Reason for Cancellation 60&h M 7 Wa\+1 W
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers, agents and employees from all
e 's or damages arising from any and all claims of action for any reason, which may arise as a result of this change of
contract r/subcontra r or cai cellation of permit. A permit can t be cancelled if work has been performed.
SIGNATURE OF OW�R (or owner/builder) — SIGNATURE GEENNERRA/L�,1CONTRAAC�T�OR/(or new GC, as applicable)
PRINT NAME 4 ,� (— j[ //s PRINT NAME it lY Ur) �J( .+ 1� �JI�_�f
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of �LL 20` _ by
TTl nn �S who is personally known to me
has
State of Florida, County of St. Lucie County
e following in ent was ac ledged before me this
day oof', 20by
1!� who is personally known to
t me or who has nroduced as ID.. I
Signature of : ota . Date Signatul o`` P 91 M A BROW N
MARY BROWN r _` P°`�sNotary Public -State of Florida
_ YPU6� Notary Public -State of Florida ; f Commission # HH 37071
Revised •= Commission # HH 37071 p = My Commission Expires
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e y Commission Expires " August 26, 2024
°in�`� August 26, 20243=-=�""""m'°E'�.""""`'. — -