HomeMy WebLinkAboutCHANGE OF SUBCONTRACTOR LEI V"EL
APR 0 4 2022
PLANNING & DEVELOPMENT SERVICES ST• Lucie Cou�tU, er;�;ittin�
0 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 FOLLOWII�JG
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 c
commencing any work There is a$90.00 fee for the Change of Contractor. copy must be submitted prior to
_x CHANCE 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 is to be signed and notarized by both the owner and
CANCELLATION OF PERMIT-The cancellation of a permit is acceptable only if no work has been done.
qualifier of record. There is no fee for
cancellation of the permit.
Date: 3 3U ZZ� Permit Number:
Site Address: 3 �- 1�-t••,a��► r�i C' -}'�I (mil e`C� L 4S(
� �I�` State License�,�C 1 Zvi 2 7 7- SLC License
Original GC,subcontract r owner/liuil er -
IGISI'1 , -- � ^ `c �<:iltiY'K �; c
1-1 State LicenseL.-i t �e�,I (�SLC License New GC,subcontractor - -
Reason for Cancellation Contract Disputes
The undersigned does hereby agree to mdemn*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
9ntraet bcontractor or cancellation of permit.A permit cann cancell�ZCMR
s been performed.
wNER(or owner/buiider) �
IrATURE GENERA (ornLLAZ�F ew GC,as applicable)
PRXNT NAME W.Bryan Adams / - /� I F'
•PRINTNAME
State of Florida,County of St Lucie County State of Florida,County of St.Lucie County
70The following instrument was aelmowledged before me this the flu lowing ins t ores aclmowledged before me this
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Alpatar fNotary ��ate SSIO // /�'� —_.`r>\ c,PRASTAZ,, V,i
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PERMIT#
ISSUE DATE
PLANNING&DEVELOPMENT SERVICES
4 Building& Code Compliance Division
BUILDING]PERMIT
SUB-CONTRACTOR AGREEMENT
(Company Nae/Individual Narne) have agreed to be
m
the HVAC
Sub-contractor for Adams Homes of Northwest, FL Inc.
(Type of Trade)
p� (Primary Contractor)
For the project located at
(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.
OIt SIGNATURE(Qualltter) SUB-CONTRACTOR SIGIUTURE 1
� (Qualifier)
W. Bryan Adams
PRINT NAME
PRINT'NA:NE
29179 _
COUNTY CERTIFICATION NUMBER
COUNTY CERT,IFICAT[ON NUMBER
Stale of Florida,County of St Lucie
State of Florida,County of Sir
The foregoing instrument was signed before me this day of The foregoing Instrument were signed before me(hisDTd y of
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20__ y —L�%��tiP.m 20Mby_
wha is personally known Y or bag produced a � �—�
who is personally known ✓or bas produced a
asid cation.tl
as t e tincation.
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Stg store otiyotary Public STAMPIlillllll/ STAMP j
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Print Name of NotaryPuouc GH27 '• i Q'1rQ ��� .• �S£11)N••'• /�i� o
P at Name of Notary Public •p UGH 27 zFrOi�• 3
i 7A•:°a 6 �5 y #HH 106177
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