HomeMy WebLinkAboutCHANGE OF SUBCONTRACTOR,. - I IAO I �_ UPS
BUILDING & ZONING DIVISI09CANNED Al 0816-
2300 VIRGINIA AVE BY A4/kjIs
FORT PIERCE FL 34982 s� love t St. Lucie County ecogn�enE
(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
Xc encing 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: :�2aM
Site Address:
Permit Number: 19 a- 0�� )
License L4 H SLC License
OrigihM GC, subcontfactor or owner/builder
1r471kfG=�State License i 3M SLC License
New GC, subcontractor t
Reason for
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 be ca celled if work h een performed.
SIGNATURE OF OWNER (or owner/builder) si NA RE GENER/ CTOR (or new GC, as applicable`
PRINT NAME PRINT NAME F1JG V ip ✓l gro
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
by
is personally known to me
or who has produced as to.
Signature of Notary Dale
Revised 04/15/16
State of Florida, County of St. Lucie County
The following instrument was acknowledged before me this
day of_ _ZIiQ,T 20 by Q�
who is personally known to
meg who has producedj, 3 L— as ID.
Signature of Not. Dale
ELLEN VAUGHN
a
_V �State of Florida -Notary Public
y®p;• Commission # GG 270079
-,;2o r My Commission Expires
non % October 22, 2022