HomeMy WebLinkAboutChange Electric subPLANNING & DEVELOPMENT SERVICES
= _ - BUILDING & ZONING DIVISION
ICOUNTY 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.
XX 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.
1107-0 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: 02/04/2022 Permit Number: 2111-0371
Site Address: 5107 Birch Drive, Fort Pierce, Florida 34982
John Cavnar State License SLC License 23575
Original GC, subcontractor or owner/builder
Jeff Matthews State License EC13006925 SLC License 29479
New GC, subcontractor
Reason for Cancellation Miss understanding
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.
os 0txn eve L-eph
ATURE OF OWNER (or owner/builder) SIGNA E O (oorr new GC, assapplicable)
PRINT NAME Arturo Nava PRINT NAME B� a vZ—�
State of Florida, County of St. Lucie County
e llowin n ent was acknowledg re me t s
��Y °f 2
who to me
or who has produced as 1D.
f N,17 iU 2
RACHEL ANN VOSSEN
Notary Public - State of Florida
e,..@
• r
Commission 4 GG t 89932
16, 2022
My Comm. Expires Apr
Bonded through National Notary Assn.
State of Florida, unty of St. Lucie County
�Tt�I lowin nt was acl ledg fo t
I
o
who is personally kno to
me or who has produced
02/ 2022
nature of otary Date
RACHEL ANN VOSSEN
Notary Public - State of Flo]Assn,
commission; GG 18993
? + My Comm. Expires Apr , 6, 2
Bonded through National Notary
Jeff Matthews
PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
ELE,-�)�-_ LLL
(Company Name/Individual Name)
the Electrical
(Type of Trade)
For the project located at 5107 Birch Drive
have agreed to be
Sub -contractor for Brian Bean ( Southern City Development, Inc.)
(Primary Contractor)
3402-608-0375-000-8
(Project Street Address 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.
CONTRACTOR SIGNATURE (Quallner)
Brian Bean
PRINT NAME
23575
COUNTN' CERTIFIC ION' 'CM FR
State of Florida. County f
3 \
Th foregoing Instrumye�n�t was sl d brfor thl \/J� y of
• by LIB LS1 -
who is '7tt"�
personally (mown 1C ��---
oPha ruducrd a _
a dentifica n
STANIP
I tore o .'otary Public
�._. .
;.�;,;,,•.• RACHELANNVOSSEN
Notary Public - State of Florida
• r= COr rrrlsslon ; GG 189932
My Cor rn. Expires Apr 16, 2022
"'gCnded through National Notary Ass
Revised II I/�16/2�016
SUB-CONTR SI 'ATURE (Qualifier)Jeff Matt s
PRINT NAME
COUNTV CERTIFICATION NUMB�E�R�p
State of Florida, County ofa
T oregoing Instrument was signed before me this day of
io,, by t
who is personally Tmown ar bas produced a
as Ifentification.
nt Name of Notary
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