HomeMy WebLinkAbout10108 Crosby Pl Permit cancellation formPLANNING & DEVELOPMENT SERVICES
. BUILDING & ZONING DIVISION
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.
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.
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: 3/29/2022
Site Address' 10108 Crosby Pl, Port 5t Lucie, FL 34986
Gensis Plumbing Services Inc
Original GC, subcontractor or owner/builder
Permit Number: 2203-0736
License CFC1429103 SLC License 29000
State License SLC License
New GC, subcontractor
Reason for Cancellation work not done
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.
SIGNATURE OF OWNER (or ownerlbuilder)
PRINT NAME
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of . 20 , by
who is personally known to me
or who has produced as ID.
3/29/2022
Signature of Notary Date
Revised 04/15/]6
eSXRq5KTURF GENtRAL CONTRACTOR �applicabe
PRINTNAME Joseph F Tully
State of Florida, County of St. Lucie County
wing instrument was acknowledged before me this
day of L � 26a� by��
1 I S-1 who is personally known to
or who has prod ed �312912Q22
BARSARAILOPEZ
ai!;.*• ;%,Commission # HH 099764
Signature of No N t Expires April 24, 2025
fir"" ",e BoadW TNu BAet Notary S43NI089