HomeMy WebLinkAboutCancel Or Transfer A Valid Permit 6-12-14Hold
Planning and Development Services
Building Division
2300 Virginia Ave
Fort Pierce, FL 34982
772-462-2165 Fax 772-462-6443
a 1-7
Harmless/Indemnity3 to Cancel or Transfer
A Valid Permit
Permit # l 3!0 -- O0 2
Property Address 2c23,2Soc
Property Tax ID #
Check one: Cancellation 1
of Permit Number 13/0- 00 77 Issued to
the following circumstances:
Dri
,t::7L 39s7
33 04/a Phone/Cell
Zip 33 V 78' Phon Cell _
SLC License email
Non -Performance of Contract _X, Transfer to New Contractor or O/B
Abandonment of Contract Contractor is Deceased __)(_ Contract Disputes
orN.cow
Further, I understand that the replacement contractor will assume responsibility for any/all work performed under this
permit.
I hereby agree to re -apply as Owner/Builder or Authorize, Gi ( Gavdvke to apply for such permit(s) as may be
necessary to construct or coW lete construction at the property listed herein.
INDEMNIFICATION: I, Y&V-ear i (Property Owner or Contractor), hereby indemnify and hold
harmless St Lucie County, its officers, a ent, 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
R
Of
Print Name
State of Florida, County of St Lucie L
The f I ing instrument was acknowledged b�f a me
this day of ' 20
by who is gersona IyAnown
to me, or w o has produced
Signature f Notary Da e
.Y P,1,
1 ANGELA M. HUFF
*c * MY COWSSION # EE 083530
jie a EXPIRES; April 12 201
,yp,';;• Bondod Thru Notary public Underwriters
Amount approved: $
S
Ai nr nature of Owner Date
, iv 1= /n 0"n y i't iCL!
Print Name 11
State of Florida, County of %ktwW[nuy%Ne—
The following instrument was acknowledged before me
this 12&' dayof JJv\. 20H
by A- txno��l-rt� who is perso�y kno /�
er, r as produce °� as ID.�6/�
griature of Notary Date
4�•r '* LISA L. CASSEL
f, Notary Public, State of Florida
Commission # EE 856175
Mycomm. expires Dec. 4, 2016