HomeMy WebLinkAboutSUB-CONTRACTOR AGREEMENTPERMIT# -45 ISSUE DATE
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PLANNING & DEVELOPMENT SERVICES
Building &�Code Compliance Division V'eceveo
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(Company Name/Individual Name)
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(Type of Trade)
PERMIT
RAGREEMENT
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vernftlng-�r_partment
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have agreed to be
Sub -contractor for AR-7;4/Z C,0A)679d0-ZZ0A) U4:�:
(Primary Contractor)
For the project located at 4#z2 IAI hlk� X 1-�
(Project Street 4ddress or Prop&ty Tax ID #)
It is understood that if there is any changel of status regarding our participation with the above mentioned
project the Building and Code Regulatio� Division of St.
I
Lucie County will be advised pursuant to the
filing of a Change of Sub -contractor notice.
CONTRACTOR SIGNAr (Qualifier)
SUB-CONTR.A.(aP%:krG_NATftE ZQualifier)
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PRINT NAME
PRINT NAME
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COUNTY CERTIFICATION NUMBER
COUNTY CERTIFICATION NUM13ER
State of Florida, County of
State of Florida, County of LAXI_A_�
day
The foregoing instrument was signed before me this day of
The foregoing instrument was signed before me this� of
20 Tby
.3
20Lq, by V2 CAM f T
who is personally known —or has produced a _F-L-
who is personally known or has produced a
as identification.
as identification.
Wa STAMP
STAAIP
Signature of Notary lie
Signature of Notary Public
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b'\'Xk\V0J
I ' ""9. _E VAUGHN
Print Name of Notary a Florida -Notary Public
-State of)
Print Name of Notary Public
-
i Commission # GG 270079
My C6mmisslon Expires
06tober 22, 2022.
ELLEN VA
eS. State of Florida-Niot'ar�yNublic
Commission # GG 270079
MY Commission
S 2 " U1,
Revised 11/16/2016 C()- IM11 . I A cz G " ,
Expires
October 22, 20
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PLANNING & DEVELOPMENT SERVICES�ecei\IV
BUILDING�& ZONING DIVISION FJ I RIO,
2300 VIRGINIA AVE
FORT PIEI�CE, FL 34982
(772) 462-1�53 FAX 462-1578
CHANG
PLEASE SELECT ONE OF THE FOLLOWING:
CHANGE OF CONTRACTOR — Chan,
and the new contractor of record for the current p(
contractor information and signature. A new Noti
for job values greater than $2,500 ($7,500 if ,
Comm cing any work. There is a $50.00 fee for
7CHANGE OF SUBCONTRACTOR — S
The new subcontractor must fill out a Subcontract
Contractor.
of Contractor is to be signed and notarized by the property owner,
iit. A new permit application must also be completed with new
of Commencement must be filed in the new contractor's name
� Change -out). A recorded copy must be submitted prior to
e Change of Contractor.
contractor changes are to be completed by the general contractor.
Agreement Form. There is a $50.00 fee for the Change of Sub -
CANCELLATION OF PERMIT — The Oancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notari ed by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
(S 14U 11 C� Igo I - o54,5
Date: �_A Permit Number:
Site Address: 14 4:2 2 IV Hw.,- A M
.5-7poAt2po SA81.�JA State License6FC /428 ffSLC License *0
Original GC, subcontractor or owner/builder
State Lice'nseCFC )42qfovSLCLicense
maoez:
New TC, subcontractor
Reason for Cancellation lc�w FV50M
The undersigned does hereby agree to indemnify and
costs, fees or damages arising from any and all claim
contractor/subcontractor or cancellation of permit. A
SIGNATURE OF OWNER (or owner/builder)
PRINT NAME
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
—day of 120_ by —
is personally known to me
or who has produced as D.
Signature of Notary Date
Revised 04/15/16
iold harmless St Lucie County, its.officers, agents and employees from all
of action for any reason, which may arise as a result of this change of
f work has b
iermit cannot be cancelled i �77 n performed.
SIGNATURE GENERAL_C01qTfR_UA�tTOR (or new GC, as applicable)
PRINT NAME 090!!�
State of Florida, County of St. Lucie County
The following instrument was ackn wled ed before me this
2—Cday of. 20JK_' b g
OL4
01cmim)(i. kAA:�Nno is personally known to
me or who has produced as ID
Signature of Notary Date
PAP&, S ELLEN V
a of F, r U G H-N
ld�-Wtary F.,blic
m �J
;79
tat 0 1
Y P State of Florldaj
is.
slo n
commission GG 270079
Conn
Y Com js�
*",-.d My Commission Expires I
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octo la 0,J
cto a r
'-�x b r 2022
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