HomeMy WebLinkAboutCancel Or Transfer A Valid Permit 01-16-14t
�. Planning and Develop Services
Building Wslon
2300 Virganea Aire
Fort plerloep FL 34882
772462-2165 Fax 7724#2-6443
Mold Harmlesslindemn1tv to Cancel Jor Transfer
A Valid Perlmit
Permit # /..11 U '
Property Address
Property Tax AD # .,
Owner
Address
Contractor Uc�o
Address -'=marr
Contractor State License
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E
L 34f95r7
33Q_ Pi�onef.Celi AS"' 74S"-2-76 9.
Phone/Geil 2=
z 5 3 2 SLC License z? o
cUM,re Residential
emaa
. Ap-t
A5 legal law or ContraCtrar (drde ores} z�7CN..__.. request
. Check one: Il;actbdlatrion Te�arrsdee� �_
of Permit Number j= P od'?..�.., Issued to an —. ZO due to
the foilowing drCUU Micas:
Non-Performmnoe of Contract -)Cct Transfer to New Contracl C or O
Abandonment of Conrad: Contractor Is Deceased Disputes
Further, I understand that the replacement eonrador vAll assume responsibility for anylall work performed under this
Layid h'tv vGr✓L to apply for such permit(s) as may be
I hereby agree to re -apply as OwneryBuWda' or Autltorize, _.
necessary to construct or co lete con coon at the p � � Contractor), hereby indemnify and hold
HND less St
�, in not limited to Building Officials), from all ems,
harmless St Lucie County. its oilicers, �, and employees ( which may arty from or pertain to this permit
fees, or damages arift from any and all claims of action for any reason,
cancellation and re -Issue request.
(Note; A copy of this notice will be sent via regular mail to the prior contractor or owner, where applicable.)
Refund Requateds _, VAS o Amount ap eds $_ . . �
Signature of Contractor We
Print Nome
State of Florida, County of St Lucie
The following instrument was acknowledged before me
this . day of 20
by _ who is personally known
to me, orwho has produced as ID.
signatum of Notary Date
Of
Print Name v
State of Florida, County of Bootle WW- w-u Oe—
The following instrument was acknowledged before me
y dvyvo)c,e_ O�
oisrn� liyknownboro as rD.o ucOd-
=� Naao/
Dante ()I - f6 -( y
LISA L. CASSEL
Notary Public, State of Florida
Commission # EE 856175
My Comm. expires Dec.4. 2016
Planning and Developmt _' Services
Building Divisiors
2300 Vergilriia Ave
Fort Pierce, FL 34982
772-462-2165 Fax 772-462-6443
Hold Harmless/Indemnity to Cancel or Transfer
A Valid Permit
Permit # 1310-- o7-7
Property Address S' O S 2- -5. 00=1JDA ,
Property Tax ID # 3 6_Z 7 S 0 1 00 3'86 (0®
Owner P L' T V_,oA_ j 1 Y1261 lM A)0A 0_VQTG Y
Address ZY080 0V50e!;MSdwy Zip 33biZ Phone/Cell 3O.a '21t.5--2-262
Contractor ocEAH- FA01 r
Address 3,q<Z2 SE DtXI E Hlri:/ X SQUZI-p 3 Y 9q7 Phone/Cell -27 2 2-66 7Sl }
Contractor State License o! 36-3 4 SLC License Z-7c� (., email Mr AR o e-aCgA.tiyi-'0I5/2S%2
Commercial Residential_— 'ern
As legal Property Owner or ontracto circle one) I, IVARJD 3U9!T!4!f request
Check one: Cancellation Transfer kt::�
of Permit Number 13fo-,06 7 Issued to EAkA &x on IA� /,61W , 20^ due to
the following circumstances:
Non -Performance of Contract 'Transfer to New Contractor or O/B
Abandonment of Contract Contractor is Deceased Contract Disputes
Further, I understand that the replacement contractor will assume responsibility for anylall work performed under this
permit.
I hereby agree to re -apply as Owner/Builder or Authorize, 06VA.4 6*4%�ef 8 o apply for such permit(s) as may be
necessary to construct or complete construction at the property listed herein.
INDEMNIFICATION: I, /))6&0 &g0liae r (Property Owner or Contractor), hereby indemnify and hold
harmless St Lucie County, Its officers, agent, and employees (including by not limited to Building Official(s), from all costs,
fees, or damages arising from any and all claims of action for any reason, which may arise from or pertain to this permit
cancellation and re -issue request.
(Note: A copy of this notice will be sent via regular mail to the prior contractor or owner, where applicable.)
Refund Requested: , yes No Amount approved: $
Date
Print Name
State of Florida, County of St Lucie
The following Instrument was acknowledged before me
this day of �`'� ►� r
by M,,)Rs n )9&L ue who ' sonally known
- - to e, or who has uce
5 nature of Notary babe `/�S�!
9 rY
++n'' •.,
'r
PATRICIA L ASKREN
MY COMMISSION 0 FF 080582
EXPIRES: January 9, 2018
✓�6
Bonded Thru Notary Pubrc Underw hers
Signature of Owner Date
Print Name
State of Florida, County of St Lucie
The following Instrument was acknowledged before me
this day of , 20
by who is personally known
to me, or who has produced. as ID.
Signature of Notary Date