HomeMy WebLinkAboutCHANGE OF CONTRACTORPLANNING & DEVELOPMENT SERVICES
BUILDING & ZONING DMSION
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(772) 462-1553 FAX 462-1578 bU NI tU
BY
St. Lucie Cow
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
commencing 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 $50.00 fee for the Change of Sub -
Contractor.
CANCELLATION OF PERMIT — The cancellation of a permit is acceptable only if no work has been done.
Cancellation of permit is to be signed and notarized by both the owner and qualifier of record. There is no fee for
cancellation of the permit.
Date: 01— / Z PV /%
Permit Number: Z2 ( / - 0 P- 3 7
Site Address: 6 S 2
"'R (i7 EZ<2i^r�GG State License Z9 6 0/ SLC License
Original , subcontractor or owner/builder
Ilan /W.., �dl-Ae,-" State License.GAG /91 16g!/2SLC License
New GC, subcontractor
Reason for Cancellation NON RESPONSIVE
"lhe undersigned does hereby agree to indemnify and hold harmless St Lucie C unty, its of cers, agents and employees from all
costs, fees or damages arising from any and all claims of action for any reaso wh' a se as a result of this change of
coactor or cancellation of permit. A permit cannot be lel i o 1 h s be ormed.
SIGNATURE OF O Mr b boil r) SIGNATURE CTOR (or n , as applicable)
PRINT NAME OoZei� ,BiJ/.✓� PRINTNAME HANDEL C. COTTERELL
State of Florida, County of St. Lucie County State of Florida, County of St. Lucie County
was acknowledged before me tbi The following in ent was ackno ledged b re met "s y. •'
! , 20L by Euer.� ----dayof. .20 , by�t f/'.Q.%./l
i_who is personally known to me who is personally (mown to
or who produc V %r as; me or who has produced as ID. �Q
/ !r 1 T I�VYr anu_ 1 o/e
Sign ve of Notary Date Signature of Notary Date
Revised 09/15/; NEIIYE �, t,E$P!<IAgCg ��—
NoYryPllL6d, SatlMFigl�
COMMdOM FF2��4 MANULETTA POLE
N1'�• I*= Ipt. P6,l01® _ Notary Public - Stale of Florida
Commission p GG 009504
My Comm. Expires Jul 6. 2020
RECEIVED
JAN 112017