Fillable Change Of Sub-Contractor Form printable pdf download

City of Pompano Beach

Department of Development Services

Building Inspections Division

Change of Sub-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

(If Acreage, attach legal description.)

Block

Lot(s)

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 sub-contractor or specialty contractor is the permit holder the owner or prime contractor 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 Sec. 104.9.4.4, 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 and any and all corrections, if required, of work

performed under the prior permit.

I, _______________________________________, the prime contractor on the referenced project, join in the owner's request for

issuance of a second permit to a sub-contractor or specialty contractor for the reasons set forth above. I further agree to hold the City

of Pompano Beach, its Officers and employees harmless and 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.

__________________________________________

Owner Signature

Prime Contractor Signature

STATE OF FLORIDA- COUNTY OF BROWARD

Sworn to (or affirmed) and subscribed before me this

______ day of ___________________, 20 _______ by

______ day of ____________________, 20 _______ by

__________________________________________.

_________________________________________.

Type/ Print Owner's Name

Type/ Print Prime Contractor's Name

___________________________________________________

__________________________________________________

NOTARY (print or stamp) as to Owner or Agent (Signature)

Name & Title ______________________________________

Personally Know ___ OR Produced Identification _____

Type of Identification Produced _________________________

Type of Identification Produced ________________________

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

Modified: 10.22.2012

Change Of Sub-Contractor Form

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