HomeMy WebLinkAboutcancellion formPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
COUNTY 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.
a 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: 10/27/2021
Site Address: x
1200 PARKLAND BLVD
Permit Number:
THOMAS F. RICHNOND ELECTRIC, INC. DBA RICHMOND ELECTRIC State License EC0001963
Original GC, subcontractor or owner/builder
New GC, subcontractor
Reason for Cancellation
2110-0220
SLC License 17642
License SLC License
CUSTOMER CANCELED WORK
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
contract r/subcontract r cancellation of permit. A permit cannot be cancelled if work has been performed.
S NATURE OF O%%�,,..��//. (or n r/b�uji er)�/ ` ATURI GENERAL CONTRACTOR (or new GC, as applicable)
PRINT t; MF 2041 ///� `_�—/ PRINT NAME $
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
27 day of October 20 2' by Lori Lee
Blazer who is personally known to me
or who has produced B426r632-63-ss2-0 as lD.
10/27/2021
Signature of 'Votary 0 Date
Revised 04/15/1 �40Fu NotaryPublicStateofFlonda
x` Deana M Dailey
My Commission GG 326515
J ry Expires 08(1212023
State of Flonda, County of St. Lucie County
The following instrument was acknowledged before me this
27 day of ,o21 by,
Christopher W. Richmond who is personally known to
e or who has produ as ID.
0/27/2021
Signature of Notary to
'� Notary Public State of Florida
:p Deana M Dailey
My Commission GG 326515
aR Expires08112/2023