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INDIAN RIVER COUNTY/CITY OF VERO BEACH BUILDING DIVISION a1°`'w 1801 27th Street, Vero Beach, FL 32960 772- 226-1260 INDIAN RIVER COUNTY/CITY OF VERO BEACH SUB -CONTRACTOR AGREEMENT/AFFIDAVIT Indian River County Contractor Certificate Number: State of Florida Certification Number (if applicable): Permit Number: has agreed to be the: (Company/Individual name) ❑ concrete ❑ stucco ❑ electric ❑ garage door ❑ other ❑ masonry ❑ insulation _ ❑ mechanical ❑ fuel gas (lines only) ❑ carpentry ❑ roofing* ❑ irrigation ❑ burglar alarm/low voltage ❑ drywall ❑ plumbing ❑ aluminum (in -fill only) Sub -contractor for for the project located at (Name of prime contractor) (Street address) It is understood that, if there is any change of status regarding our participation with the above mentioned project, I will immediately advise the Indian River County Building Division by personally filing a Change of Contractor. *Roof coverings other than asphalt shingles, wood shingles or wood shakes require a licensed roofing contractor. ******************************************************************************************************** SUB -CONTRACTOR QUALIFIER PRIME CONTRACTOR QUALIFIER (Main Permit Holder Information Required) Signature: Printed Name: Date: Business Name: Address: City, State, Zip: Phone: Notary as to Sub -Contractor: STATE OF FLORIDA, COUNTY OF Sworn to and subscribed before me this 20 , Signature: Printed Name: Date: Business Name: Address: City, State, Zip: Phone: Notary as to Prime Contractor: STATE OF FLORIDA, COUNTY OF day ofI Sworn to and subscribed before me this day of 20 , by who is ❑ personally known or ❑ produced identification Type of ID produced Printed Name of Notary Signature of Notary Notary Seal by who is ❑ personally known or ❑ produced identification Type of ID produced Printed Name of Notary Signature of Notary Notary Seal Page 6 of 9