HomeMy WebLinkAboutCHANGE OF CONTRACTOR1 PLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982 81OZ 61 8VA
(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: T1 -Z-61 tb
Permit Number: 1 —112 r b q�a o
Site Address: lz�`t q ef(G-w S� uo?__
1 State License D!`� Zb SLC License
Original C, subcontractor or owne�'�
ilder
�V�n ��LQ State LicenseQj�C\AZ.945,,SLC License
New GC, Wcontractor
Reason for Cancellation
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 i H d if work has been performed.
SIGNATURE OF OWNER (or owner/builder) Sf,Pt_P'VAE GENERXCCONTRACTOR (or new GC, as applicable)
PRINT NAME&t6,1\ W - CAU\115- PRINTNAME��C'Jl/ theVl tit RLJ
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
ay of 201�, by
who is personally known to me
r who 4 produced Z as ID.
State of Florida, County of St. Lucie County
TIi following instrrum`egt was ac ledged before me this
day of 0 4!/( 20 , by
n2,I10Ako11-J who is personally known to
me or NZ
�edas ID.
3rgnarure or ivorary 'oars Sign ure of Notary Date
r Pu Notary
Public State of Florida r
Revised 04 /15/16 x� ,�sG: Sandra Leone GG 020251 < '+ o��r Peen Notary Public State of Florida .,
�; My Commission C Qy Sandra Leone
Expires 0811012020 Ngcvec My Commission GG 020251 tt
OF P° �'pF p,O Expires 08/10/2020