HomeMy WebLinkAboutCHANGE CONTRACTORSCANNED
BY
_ PLANNING & DEVELOPMENT SERVICES
=1 - BUILDING & ZONING DIVISION eD
2300 VIRGINIA AVE JAA1®72019
FORT PIERCE, FL 34982 Ae S tog pepart
(772) 462-1553 FAX 462-1578 Cucle Cough ent
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/slues greater than $2,500 ($7,500-if A/C Change -out). A recorded copy must be submitted prior to
corm crag 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: /7Permit Number: j 9 � � - OR,)—o
Site Address: % �()� /� t° {�00 I1-P z
o �G� State LicenseS//ySSLCLicense 2"q(0(,,3
Original G , subcontractor or owner/builder `G fyj G
C t/d" /0 /-? ci State License SLC License O c-s
New GC, subcontractor
Reason for Cancellation
The undersigned does hereby agree to indemnify and hold harmless St Lucie County,)is officers, agents and employees from all
costs, fees or damages arising from any and all claims of action for any reason, whic 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 owner/builder)
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.
Signature of Notary Date
Revised 04/15/16
SIGNATURE
PRINT
(or new GC, as applicable)
l;u-W ka,dl,P,
State of Florida, County of St. Lucie County
The foQllowing instr�u�e�`n�t -w�as acknowledged bef re a this
ay of / G(/l , 20�, by J/ -t/
me
Rebecca Dima
�= ire5; danu� NotaN
� �= BOO �ro
I PERMIT#
/ a 6 ( _ - 0S)__0
ISSUE DATE
PLANNING &,DEVELOPMENT SERVICES
Building & Code Compliance Division
ELECTRIC CONNECTION
(Company Name/Individual Name)
ELECTRICAL
(Type of Trade)
BUILDING PERMIT
SUB -CONTRACTOR AGREEMENT
Sub -contractor for GHO HOMES
Foljlthe project located at MEADOW WOOD- #95
(Project Street Address or Property
(Primary Contractor)
-7 v`7
ID #)
have agreed to be
)n
It i� understood that, if there is any change of status regarding our participation with the above mentioned
ect, the Building and Code Regulation Division of St. Lucie County will be advised pursuant to the
of a Chadhe of Sub -contractor notice.
e of Florida, County of � C/ G
foregoing instrument was signed before me this / day of
2041by -Pi
is personally known or has produced a
Name of Notary Public
� tiss�oo
Q�y\:�v�,, Comm a0,4049,
= icy
=z; ill''• tppN
.�. �. �
,d 11/16/2016
SUB -CONTRACTOR SIGNATURE (Qualifier)
RANDY SJAARDEMA
PRINT NAME
21055
COUNTY CERTIFICATION NUMBER
State of Florida, County of ST LUCIE
The foregoing instrument was signed before me this 3 day of
JANUARY , 201 Q by RANDY SJAARDEMA
who is personally known X or has produced a
as identification.
AMP STAMP
Signature of otary ulic
Print Name of tary Public
�Y'p�e.• SITYAN T BROmELOW
4 Notary Public - State of Florida
�t,7 Commission GG 26371
oFn: ` My Comm. Expires Oct 17. 2022
Bonded through National Notary Assr.