Fillable Change Of Prime Contractor Form printable pdf download

City of Pompano Beach

Department of Development Services

Building Division

Change of Prime Contractor

100 W. Atlantic Blvd Pompano Beach, FL 33060

Phone: 954.786.4670 Fax: 954.786.4677

Permit Number: _______________________________

Date: ___________________________

Job Address: ______________________________________________ Pompano Beach, FL _____________ (Zip Code)

________________________________________________________

_________________

__________________

Subdivision

Block

Lot(s)

(If Acreage, attach legal description.)

Job Description: __________________________________________________________________________________

Original Contractor: _______________________________________________________________________________

Proposed New Contractor: __________________________________________________________________________

Florida Building Code

Broward County Amendments Chapter 1 - Administration

105.13.4 Upon request of the owner and/or permit holder and on investigation by the Building Official to determine that the work has been

abandoned or that the contractor is unable or unwilling to complete the contract a second permit may be issued where there is a change of contractor

without the initial permit being revoked or suspended.

105.13.4.1 The foregoing will be permitted only when the following stated persons have filed with the Building Official a letter stating the

reason for a second permit being required and holding the Building Official harmless from legal involvement. All interested parties shall be

notified before action is taken.

105.13.4.1-1 Where a prime contractor is the permit holder the owner shall both file such hold - harmless letter.

Hold Harmless

BUILDING OFFICIAL:

As legal owner of the above mentioned property, and pursuant to the Florida Building Code, Broward County Amendments Sec.

_____________________

105.10.4.4, I request issuance of second permit for the referenced project, for the following reasons:

________________________________________________________________________________________

I HEREBY apply as owner, or authorize ________________________________________ to apply for such permits as are necessary

to construct or complete the construction on referenced property.

I agree to hold the City of Pompano Beach, its officers and employees harmless and to relieve the City, its officers and employees

from any responsibility or liability for any legal action or damage which may result from the issuance of a new permit.

I further acknowledge that as the owner, I am responsible for compliance with the code of any and all corrections, if required, of work

performed under the prior permit.

_________________________________________

Signature of Legal Owner/ Agent

STATE OF FLORIDA- COUNTY OF BROWARD

Sworn to (or affirmed) and subscribed before me this

______ day of ___________________, 20 _______ by

_______________________________________.

Type/ Print Owner's Name

_________________________________________________

NOTARY as to Owner or Agent (Signature)

Name & Title

(print or Stamp) ____________________________________

Personally Know ___ OR Produced Identification _____

Type of Identification Produced ________________________ __

G:\Zoning 2009\Forms and Sample documents\Website Documents\Building\Forms\change_prime.pdf

Modified: 12.14.2012

Change Of Prime Contractor Form

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