HomeMy WebLinkAboutCANCELLATION OF PERMIT _ PLANNING & DEVELOPMENT SERVICES
4 = BUILDING & ZONING DIVISION
► F
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: J hO� �bZ I Permit Number: 2109-0299
Site Address: -7913 1-19M k r or� S�- LaGc. TL- 3L4 q F G
PDKRoofing.lnc Dee Keihn State License CCC1331408 SLC License
Original GC, subcontractor or owner/builder
State License SLC License
New GC,subcontractor
Reason for Cancellation Customer Cancelled
The undersigned does hereby agree to indemnify and hold harmless St Lucie County, its officers,agents and employees from all
cost ees or damages arising from any and all claims of action for any reason,which may arise as a result of this change of
co tra for subcon a r or can Nation of permit.A permit can a cancelled has een performed.
SIG TURE OF ER(Or owner ilder) SIGNATURE GENE CONTRA OR(or new GC,as applicable)
n
PRINT NAME VGe. k t M PRINTNAMF Dee Keihn
State of Florida,County of St.Lucie County State of Florida,County of St.Lucie County
The following.i trument was acknowledged efore me this
-- Thhffbllowing i me was ac Qwledged before me this
flay of 2��,by � (fit `�day of t_. 2 i,by
who is ersonally known to me t_ k- K """" who is personally known to
or ho as prod as ID, me r , o has pro a e as ID.
Sig store of(Votary Date Sig ture of tary (Date ,
ALEXANDERAGUIRREi� ALE(AhIDERAG
MY COMMISSION Revised 04/15/16 d¢tA'17:
=; UIRRE
MY COMMISSION#GG 234811
EXPIRES:July 4,2022EJtPiRE
'of Ftia, Bonded Thru Notary Public Underwriters S:July 4,2022
Bonded Thar Notary Pub33c undervaiters