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Planning&Development Services
6i Building&Code Regulations Division
2300 Virginia Ave.
Fort Pierce,FL 34982
(772)462-1553 Fax 462-1578
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 AIC 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 Sub-Contractor Agreement Form.There is a 550.00 fee for the Change of Sub
C2�ICAANcELLATm
ax.
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
cancellationof the permit.
Date: `�" 1 ""��- Permit Number: 'jLC ! 1 ~of 9a
Site Address: 14 Ph AR ,Z-►S �{
Edward I Heritage _..__-State License SLC License 57 f(0
Original GC,subcontractor or ownerlbuilder
State License SLC License
New GC,subcontractor
Reason for Cancellation
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 as a result.of this change of contractor/subcontractor or cancellation of
permit. A permit cannot be cancelled if work has been performed.
S GNATURE.OF OWNER(or owner/builder) SIGNATURE GENE 0N7rR OR(or new GC,as applicable)
PRT_NT NAME P.R[NTNAVIE__ ere Q
State of Florida,.County of St.Lucie County state of Florida,County of St.Lucie County
The following-instrument was acknowledged before me this The following instrument was acknowledged before me this
ay 20 ,by (!day of_ �_z,t aolL;by------Edward I Heritage
who is personally know to me whos pe=k.,u,
it who has produced as ID. orr9
produced as ED.
g. r4• �
Signature of Notary Date Signature or Notary Date
at Ass PAMELA A.EVANS
Revised 04!15/16 0� ��NOTARY PUBLIC
m 5• STATE OF FLORIDA
Y. .Comma#FF1509967
S�rcE►e�� Expires 10111/2018