Instructions:
1. The permit applicant and the existing qualifier must sign this form. Both signatures must be notarized. Please print
clearly or type the information.
2. Submit this completed form and a new permit application containing the new contractor information.
Date: ____________________ Permit No.: _____________ Folio: ______________________
Job Address: ________________________________________________ Unit No.: _______________
I (We) agree to hold the City of Hialeah, Building Official, and authorized personnel harmless and relieve them from
any responsibility or liability for any legal action or damage, cost or expense (including attorney’s fees) resulting from
the change of contractor. I furthermore assume responsibility for the work being performed under this permit for which
I am requesting a change of contractor. In the event there has been a change of ownership of the property, the new
owner assumes the responsibility of notifying the previous owner of his or her intent to transfer the permit.
Reason for Change of Contractor: ____________________________________________________________
_____________________________________________________________________________________
Owner-Tenant Information
Name: __________________________ Signature: _____________________ Phone: _________________
Address: ____________________________________________ E-Mail: ___________________________
State of Florida, Miami-Dade County Sworn to and subscribed before me this ___ day of _________________.
By ___________________________ Personally known
□ or produced identification __________________
Notary Signature: _______________________ Seal:
Existing Contractor Information
Name: __________________________ Signature: _____________________ Phone: _________________
Address: ____________________________________________ E-Mail: ___________________________
Company Name: ____________________________ Qualifier Name: ______________________________
State of Florida, Miami-Dade County Sworn to and subscribed before me this ___ day of _________________.
By ___________________________ Personally known
□ or produced identification __________________
Notary Signature: _______________________ Seal:
Approved: __________________________ Date: ___________________
Alexis Riveron, Building Official
Rev. 11.5.14
City of Hialeah
Building Department
501 Palm Avenue, 2
nd
Floor, Hialeah, Florida 33010
Office: 305.883.5825 Fax: 305.883.8082
www.hialeahfl.gov
Change of Contractor Request – Hold Harmless
