HomeMy WebLinkAboutCHANGE OF CONTRACTOR7ES
ECEIVED
PLANNING & DEVELOPMENT SERVI OCT 0 4 2018
BUILDING & ZONING DIVISION ST. Luc county, Permitting
2300 VIRGINIA AVE
FORT PIERCE, FL 34982
(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
comm cing 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: Zb� &Z,� Permit Number: ��G�— 0/0 3
Site Address: �Cl `rC/ 0:�e,4 ✓ hi p 01711 % 9`
,4LL /F�1��4C_ ���(/�� State License SLC License +5
Original GC, subcontractor or owner/builder S F�eC- ,l _, PLC-- State License E(_'i ?,CCQSLLC License
New GC, subcontractor
Reason for Cancellation G,LL 06p:r Dr' _d%
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 cancelled if work has been performed.
SI�GP A`fURE OF OW R t&owner/builder) SIGNATTJRE GENERAL
1'{JI'/�+-�7yRALL CO�NrT�RAACTOR( r new GC,
was applicable)
PRINT N '[, (TkryY, �q �n.pjy)(1 PRINT NAME
State of Florida, County of St. Lucie County State of Florida, County of Si Lucie County
The following instrument was acknowledged before me this Tlj5fiallowingi t t was ac wledged before me this
_day of , 20_, by
day of -TT 2In by
who is personally known to me
or who has produced as ID.
Signature of Notary Date
Revised 04/15/16 SCANNED
BY
St. Lucie County
has
is personally known to
_, ID.J�u-if33—(,o5•021—a
ELIZABETH MEE
MY COMMISSION # GG 241752
EXPIRES: Juty 25, 2022
Bonded That Notary Public Undemitei
OCT 0 4 2018
ST. Lucie County, Pem
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL OD
c. T< :�..�< nz< �.r-..< a c�< A<.:�<.:�<.:. c�< �< ��< a<i-.�c:�< �c r..r.� r av-.� .:�f<.r—..<f-.�• :mot 1 .
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County oeAViVNQ,
On , "h 70 )) before me, e)Yftr o Cee 1 a nn ` r)de-zy��,�
Date Here Insert ly,@me and Title of th�Offic r
personally appeared
Names) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
BBIANNA LEE HERNANDEZ
Notary Public -California a
San Diego County 5
- Commission t 2212025
My Comm. Expires Aug 28, 2021
Place Notary Seal Above
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
WITNESS my hand and official seal.
Signat re
Signature of Notary Pub c
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document:
Number of Pages:
Document Date:
Signer(s) Other Than Named Above:
Capacity(es) Claimed by Signer(s)
Signer's Name:
❑ Corporate Officer — Title(s):
❑Partner — ❑limited El General
❑ Individual ❑ Attorney in Fact
❑ Trustee ❑ Guardian or Conservator
❑ Other:
Signer Is Representing:
Signer's Name:
❑ Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑ General
❑ Individual ❑ Attorney in Fact
❑ Trustee [I Guardian or Conservator
❑ Other:
Signer Is Representing:
02014 National Notary Association • www.Nationa]Notary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907