HomeMy WebLinkAboutCHANGE OF CONTRACTORPLANNING & DEVELOPMENT SERVICES SCANNE0
BUILDING & ZONING DIVISION t LUC e COUI1�y
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
co c•rag 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: �- a -1
Site Address: ) C4 0 l a C/-
Permit Number: / 2 ^ (/ CC / T.
State License SLC License
Original GC, subcontractor or owner/builder
e C-} h C_ State License �S Q 0� 5 I5 SLC License
New GC, subcontractor
Reason for Cancellation _�)dfl+ f'-e �,j ('f) ('c. I [ S r V) 4 r �_ 4,o o<si- _ Cc ho ) A O --
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 an as h h may arise as a result of this change of
c ctor/subcontractor or cancellation of permit. A permit cannot e a e ed if ork has been performed.
SIGN TURE OF OWNER weer uilder) SIGNA GE - CONTRA O vr,*_ Cp pp�caljl_eJ,,�
PRINT NAME�c��(1arCV OCRriC11?�� PRINT NAME Lau
State of Florida, County of St. Lucie County
The following " trument was aclmoo ledtj beyfoore me this ,� O /
day o 20/by.Y t'/W N r7 YC.f 17
• o is per onally known to me /
or who has nroduc I • (Ir.. C-
Signature of Notary ( I Date
Revised 04/15/16
k" AUDREY B. HUMPHREY
* *= MY COMMISSION # FF 174772
iX.oQs EXPIRES; March 6, 2019
'I - RE BoededThruNotarypublicUnderwriters
State of Florida, County of St. ucie County
T ie following instrument was ackng ledgpd of a rs pw
day of 20 66 by i�
who is personally known to
Signature of Notary Date
ID.
- z3-18
BRENDA ROMERO ZELAYA
Notary Public - State of Florida
Commission # GG 208712
My Comm. Expires Apr 18, 2022
90rded through National Notary Assn.
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i�
PLANNING & DEVELOPMENT SERVICES
Building & Code Compliance Division
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
�r'yX P K;xk()rn �
wom nycj ,41ncAndividual Na e)
thel�efe�'
(Type of Trade)
For the project located at i 5 ��
have agreed to be
Sub -contractor for Zx(ALI/}S lY' 6alz�T }lpm-i rxvuc-eq
(Primary Contractor)
ail re si°OMAoperty 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.
'off• Nu,.x
PRINT NAME
-1'&/i/ 2, 3i 3 6
COUNYV CERTIFICATION NUMBER
State of Florida, County of SA I UC re
The foregoing instrument was signed before me this day of
23 , 20_�,a by
who is personally known or has produced a
as identification.
3RENDA ROMERO ZEUYA
'+atary Public - State of Florida
Cammission
Signature of No a ry lic • Comm. Expires Apr 18, 2022
11 �t • through National Notary Assn.
F1��CJGt � - -'1G� 7
Revised 11/16/2016
0--) Q_ 00 k �Q M
CODIFICATION NUMBER
State of Florida, County of S'F I tiL i e 1
The foregoing instrument was signed before me this ! day of
3 ,20A by — y
who is personally known _or has produced a U
as identification.
; ;�•!",yr . BRENDA ROMERO ZEUYA
Notary FAcbT&Afflte of Florida
signature of otary Public �,a`, Commission # GG 208712
\' My Comm. Expires Apr 18, 2022
tre t \ LIJC *a C through National Notary Assn.
tjt `mot r�•+.��
Print Name of Notary Public