____________________________________________________________
_________________________________________
VOID / CANCELLATION OF APPLICATION / PERMIT
Date: _____________________
Permit No: _________________________
Address of Project: ____________________________________________
License Number:
Licensed to:
Company:
As the license holder, who submitted for the above referenced application /
permit, I am requesting the application / issued permit be voided because
.
License Holder Printed Name Signature
STATE OF FLORIDA )
COUNTY OF ____ )
Sworn to and subscribed before me by means of [ ] physical presence or [ ] online
notarization, this _____ day of _________________, 20___, by ______________________
_____________________________ (name of person acknowledging), who is [ ] personally
known to me; or [ ] has produced __________________________ as identification.
Signature of Notary Public (Seal)
1101 EAST FIRST STREET SANFORD FL 32771-1468 PHONE (407) 665-7050 FAX (407) 665-7486
bpcustomerservice@semiolecountyfl.gov