HomeMy WebLinkAboutChange of Contractor�1
PLANNING & DEVELOPMENT S:
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR — Change of Contractor is to be signed and nota
and the Bew ow*wter of moorxd for the cu raA permit. A new pemait application must 2
contractor information and signature. A new Notice of Commencement must be filed in
for job values ,greater than $2,500 ($7,500 if A/C Change -out). A recorded copy in
•conm=cmg any work. There is a S50.00 fee for the Change of Contractor.
_)(_C&Q9GE OF'SUBCONTRACTOR — Subcontractor granges are to; be complete
The new subcontractor must fill out a Subcontractor Agreement Form. There"is a $50.00
Contractor.
CANCf LLATION OF PERMIT — The cancellation of a permit is acceptable on
Cancellation of permit is to be signed and notarized by both the owner and qualifier of
cancellation of the permit.
rloq., oqW
d by the property owner,
be convf eted with new
new contractor's name
be submitted prior. to
by the genital contractor.
is for the Change of Sub -
if no work bas been done.
cord. There is no fee for
Date: 7115=16 Permit Number: 170"24
Site Address: 13196 NW Wheaton
CJM Roofing State License SLC License 28663
fiMgind'0C, subcontractor or otwnedbui'lder
All Phase Roofing State License SLC L'ioense 30265
New GC, subcontractor
Reason for Cancellation
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 Wresult of this change of
contractor/subcontractor or cancellation of permit. A permit cannot be cancelled if work has been performed.
SIGNATURE OF OWNER (or owner/builder)
PRINT NAMESC.o-CC t^-c�f CL� C.L
State of Florida, County of St. Lucie County
The following instrument was aclmowlcdgcd before me this
1 b dayof J UTA 20 t , by
St'm IAMC C Ac. wlto;is pMWWl1y kW -tome
who
o has P od as ID.
7/15/2016
SIGNATURE GENERAL CONTRACTOR (o new GC, as applicable)
PRINT NAME
State of Florida, County of St. Lucie County
The following do trumem was admowledged I
I,—dayof ���—. 20j_%by
Q-T[ 140 fCL1G_ i wbois po mee
me rWo has produced as ID.
lure of Nohry DateV tore of Notary Date
1
Revised 09,/15/16
me this
I®oaA to
o�r'a�ttit�e r 7 °;��c•
o ;2 tGr, C, 6373 �.
cQ 0'
's�• ci a l!n e.e �v ° Y J�: \o�'m
PER # ISSUE DATE
PLANNING & DEVELOPMENT SEP ICES
Building & Code Compliance M4Ision
BUILDING PERMIT
SIM-CONTRACTOR AGREEMENT
ALL PHASE h
(Company Name/lxdividual Name)
the ROOFING Sub:contractor for STANDARD PACIFIC
(Type of Trade) (Primary CUnt&CiQr)
For the project located at 13196 NW Wheaton Palm City Florida
(Project Street Address or Property Tax ID'
It is understood that, if there is any change of status regarding our participation with
project, the Building acid CodAegulation Division of St. Lucie County will be advi
agreed to be
FLORIDA GP,INC
above mentioned
pursuant to the
filing of a Change of Sub -contractor notice.
CONTRACTOR SIGNATURE (Qusar r) SU CTOR SIGNATURE (Q
SCOTT HARALA�
PRINT NAME PRINT NAME
SLCO 2SM/CGC 1506052
COUNTY CERTIRCATION NUMBER COUNTX CERTJFJCATJON NUMB.
State of Florida, County of State of Florida, COANty of
The foregoing ina mmeut was stgmd before we this day of The foregoing instrumeot was signed
20_, by . 2A b9
who is persomlly known or has produced a who is personally know or has
otilication. • ' as ideotwCation.
STAMP
S adire Or NOWT PuMHc r of Notary PabHe
w a (V.e'
• Print Nas,x of Notary P Print Name of Notary Pnhric
. +di1;91
• ,� e�r,7Ca� ..l 1!,
Revised 11/1612016
me this &Ay Of
a
A1ina N. Pam
COMMMIONNIM
EXPIRE& Jana fir M
89111i1d �iAll tAtlnll