HomeMy WebLinkAboutCOC 1906-0537S PLANNING & DEVELOPMENT SERVICES
BUILDING &.ZONING DIVISION
2300 VIRGINIA AVE
. k 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 o%N ner,
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 (S7_500 if A/C Change -out). A recorded copy must be submitted prior to
corruDencing 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 trew subcontractor must fill out a Subcontractor Agreement Form. There is a S50.00 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: 1-6 T C40 a
Permit Number: C _ 090-6 -053-�
Site Address•.'5�^t►t�`�}rt�
LL 0_ State License SLC License
Original GC, subcontractor or owner lder
-�• ��l � �1 0�1LW--State License tk\. License
New GC. subcontractor �1w
Reason :for Cancellation
The undersigned does hereby agree to uidenurify and hold harmless St Lucie Count3 ,its officers, agents and employees fromall
costs, fees or darnages 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 pernut. A permit cannot be canjelled if work has been performed.
S ZiNIMHU", F ONN NER {or ovvneffbuader} SIG\. TL GE. FR3I, CO I rI2ACTnR (ar ne« GC; as applicsble)
PRINT NAME_l- 1tibXC `Q-\ V PRINT NAME_
State of Iilod.da, County of St. Lucie County
The following instrument ,.Nw, acc�lmothiedged�bnefore me this
day o0�J1'_ Z, , by ` \A
KSO 1 i�o i ersonally Imo- o me
or -who has produced
'�_—R
State of Plorida, County of St. Lucie County
The ollowin tstrument
_day
ie aclmowleciged efore n3e this
af���, by��
me or v tbo has
is personallyimo-n to
AMAN :PRAYER I signature of F.0
pyii DA PRAYER
:Notary Public State of Florida `e'-
�yNOtary Public -State ofFlorid
commission 4 HH 192119 , commission # HH 192119
MyCommission ExpirosMy Commission Expires
October 28,2025 is "` October 28, 2025