HomeMy WebLinkAboutChange of Contractor- owner builderPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGNIA AVE
W. .------ 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: A k � a," \
Permit Number:
Site Address 3� 9� 02,E .1t -1�-� (` f �� ePce
C '��QQ,\k _State License SLC License
Original GC, ssubcontractor or o er/builder
-pX State License SLC License
New GC, subcontractckr
Reason for Cancellation I C 0
leav/`-Lf As
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.
01
SIG OF O (or owneribuilder) SIGNATURE GENERAL CONTRACTOR (or new GC, as applicable)
RINT NAME I Gen,a s PRINT NAME
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
__t_dayof Nt _20_QA6 by &QiVG�5
who is personally known to me
or who has produced P / -P&L— as ID.
Revised 04/15/16
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of , 20_, by
who is personally (mown to
me or who has produced as ID.
stag oNdaAU
Commission q Gotary public
G 270
Fyn ommission E.""9
of Notary Date
PERMIT # ISSUE DATE
PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
I
vQl%Ltea, " ✓,!J
(Company Name/Individual Name)
the
For the project located at
(Project Street
have agreed to be
Sub -contractor for
C (Pr' ry Con ontrraactor)
405 9� ,
or Property Tax ID #)
It is understood that, if there is any change of status regarding our participation with the above mentioned
project, the Building and Code Regulation Division of St. Lucie County will be advised pursuant to the
filing of a Change of Sub -contractor notice.
CONT OR GNATUR Qualifier)
�QI, a r -�-
PRINT NAME
COUNTY CERTIFICATION NUMBER
State of Florida, County ofs�-� t
The foregoing instrument was signed before me this IR, day of
20L( by
or has produced a
who is nersnnally known
SUB- CTOR SIGNATURE (Qualifier)
NN r•
T m c Pi iD/�t'fa �S
PRINT NAME
COUNTY CERTIFICATION NUMBER
State of Florida, County of 5—JLwr
The foregoing instrument was signed before me this 9- day of
202tby
who is personally known or has produced a V
erg Wl eItea knr>'z W i &i �!1
m
Print Name of Notary Public Print Nae of otary Pudic
KAREN S. NIELSEN
State of Florida -Notary Public
_* •- Commission #GG 207484
�.� My Commission Expires
June 12, 2022
Revised l
___-3Tr4MP
KAREN S. NIELSEN
State of Florida -Notary Public
�? Commission 0 GG 207484
o My Commission Expires OF FL P
June 12, 2022