G:\Zoning 2009\Forms and Sample documents\Website Documents\Building\Forms\change_prime.pdf Modified: 12.14.2012
City of Pompano Beach
Department of Development Services
Building Division
100 W. Atlantic Blvd Pompano Beach, FL 33060 Change of Prime Contractor
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 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 ________________________ __
