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� � <br /> � AUTHORIZED AGENT AFFIDAVIT <br /> '. ��� r �. � CITY OF ZEPHYRHILLS Date: <br /> "-4' 5335 8TH ST <br /> ;;_, t��• ZEPHYRHILLS FL 33542 <br /> �,,\ (813)780-0020/(813)780-0021 fax <br /> �, I ROBERT W DOLLAR designate the individuals listed below as Authorized Agents <br /> (Qualifier/Contractor Name) <br /> of FIRST FLORIDA CONSTRUCTION & REMODELERS,to act on my behalf, or on behalf of the prior named <br /> (Company/Corporation Name) <br /> company/corporation in processing permit applications and conducting activities related to obtaining <br /> permits from the City of Zephryhills. The activities include signing all documents required of the Qualifier or <br /> Contractor. <br /> The signature of the Authorized Agent is binding and causes me to assume all responsibilities and penalties <br /> connected to and associated with the AgenYs signature as it may relate to my business. In addition, I authorize the <br /> Authorized Agents to bind me, and/or the corporation,to pertorm any requirement necessary to obtain the permit. <br /> I the undersigned, agree to hold the City of Zephryhills and all employees of The City of Zephryhilis <br /> harmless from any and all damages, claims or other actions that may occur by reason of the Building <br /> Department acceptance of the Authorized Agents signature for permit application activities. I further <br /> understand that is my sole responsibility to designate and terminate authority and to ensure that the <br /> Building Department receives timely written notices of any changes in the AgenYs status. <br /> I the undersigned, being the contractor as either an individual or qualifier of a corporation, do hereby <br /> affirm that all information on this form is true and correct. <br /> ���>>������ CCC032512 <br /> S�ignature of Qualifier/Contractor DBPR or Pasco County Number <br /> 3909 DORAL DR TAMPA, FL 33634 <br /> Address <br /> Notary for Contractor's Signature Authorized Agent Printed Name Initlal by <br /> STATE of FLORIDA <br /> COUNTY of HILLSBOROUGH 1) JOHN P ALBANO <br /> The foregoing was acknowledged before me this 4 day 2) ROMAN F ALBANO <br /> of MAY ,20 16 by s) WILLIAM E MOORE <br /> ROBERT W DOLLAR , a� <br /> (name of person acknowledging),who is personally known to <br /> me,or who produced DRIVER'S�LICENSE 5) <br /> ` t e of identification) <br /> � I <br /> NOTARY PUBLIC� r <br /> 4�pY p(��i <br /> ,�•• �; IMWAM E.MOORE <br /> 5*� � MY COMMISSION�EE 843509 <br /> ��. �; EXPIRES:Octaber 16,2016 <br /> p,'��h,�• Bonded Thru Notary public Underwriters <br />