HomeMy WebLinkAboutCANCELLATION OF PERMITPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DIVISION
2300 VIRGINIA AVE 113GANNED
FORT PIERCE, FL 34982 8,Y
(772) 462-1553 FAX 462-1578 ucie COunty
CHANGE OF CONTRACTOR, SUBCONTRACTOR OR CANCELLATION OF PERMT
PLEASE SELECT ONE OF THE FOLLOMNG:
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 $2,50D ($7,500 if A/C Cbange-out). A recorded copy must be submitted prior to
commencing any work- There Is a S50.00 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 S50.00 fee for the Change of Sub -
Contractor.
—_K--CANCELLATION OF PERMIT — The cancellation of 4 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 perrait.
'�� I
;i- /,;L0 —Oc
Date: t Permit Number:
1 1
Site Address. f,_1 (f / 4�,1,5 1,1 L OZt
<*
3
GY'9 ' rl S At C, :tj!�/C� State Lircnskl'S I ?-- 00.1LIC License
Original GC, subcontrarioior owneribuilder
State License SLC License
New GC, subcontractor
Reason for Cancellation (' 1E
The undersigned does hereby agree to indemnify and hold harmless St Lucia County, its officers, ageras and employees from all
costs, fees or damages arising from any and all claims of action for any reason, hi h
w_ in ma a result of this change of
iontractor/subcontractor or cancellation ofpcmiit. A permit cannot be cancelled if wor h "enperformed.
SIGNATURE OF OWNER (or ovmebuilder) SIGNATURE GENEJtAL CTO?IS4)r new GC. n aisilic*t)
PRINT NAM:; PRINT NAME
StaW of Florid� County of St Uude Cmmty
The follouing iaomrnmt was adm�ledgcd befom me this
20 by_
_%bo is pc�soaatly knovm to me
or %ito has PmhCC4_as D.
Sign2tureof.Nmary Date
Revised C4/15/16
SLUC Of Flodda, COWny Of SL LUcit COUnty
TIM followinginstoment %as aelcqowl�lgcd before ma this
/p7_,(4_dayO1--_&6� 20a-by_W_Af-1Qjo, C I
14
who is per�
Ily kno" W
me or wim lim prodazed —as 11)�
42n,%C4k-) Z�, 'C"'L _57-11Llle,
Signmiore of Noury 4ft
WANDA L. CIMAOLIA
AVY CON%GSSION 0 FE000633
MWIMi Nqan:h25,2D17