HomeMy WebLinkAboutWS 25 - CHANGE OF CONTRACTORPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982 LOT 25
(772) 4624553 FAX 4624578
CHANGE OF CONTRACTOR. SUBCONTRACTOR OR CANCELLATION OF PERMT
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR —Change of Contractor is to be sighed 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.
Xxx CHANGE OF SUBCONTRACTOR — Subcontractor changes are to be completed by the general contractor.
The new subcontractor most 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: 12/8/2021 Permit Number: SLC 2104-0686
Site Address: 5126 ARMINA PLACE
FAMILY AIR, INC State License SLC License
Original GC, subcontractor or owner/builder
Uuj)e;Y DM NJG4tZ1jmQ,,m& State Licens SLC License
New GC, subcontractor
Reason for Cancellation Non -Performance
The undersigned does hereby agree to indemnify and hold harmless S ]
costs, fees or damages arisin from any and all claims of action fora y
contractor sub r to r cancellaFftof permit. A permit canno be
SIGNATURE O/ !R (or ownerPouitder) SIG
eR>NT NAME Kevin Borkenhagen
Slate of Florida, County of St. Lucie County
The following instmment wes acknowledged before me this
24 dw of June m 21 by
is IiOATHLEEN F. INGERSOLL
MY COMMIS310N q HH 182271
of Notary
Revised 09/15/16
�, agents and employees frog
as a result of this change of
new GC, as applicable)
C. Lindstrom
State of Florida, County ofSt. Lucie County
The following instmment was acknowledged before me this
t� day of +^+ ZO'_,by Wrrmc.umaam
wh ersonall aGm to
meor to has pr uced�_as 1D^ICI '
Signature of Notary l! DateV
,��AGIBBS
MY COMMISSION8GG108105
EXPIRES: APIi122, 2022
Bonded Thtu Nalaiy Publie Undenvrile m