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<br /> � � m D � ► �
<br /> PERMIT AGENT AUTHORIZATION FORM
<br /> ALL INFORMATION IS TO BE TYPED OR LEGIBLY PRINTED
<br /> I, Anthony Gonzalez CAC1816958
<br /> (Contractor's Name) NOT COMPANY NAME (Contractor's License No.)
<br /> hereb authorize the following to act as my agent(s) in obtaining permits in City of Zeph rhills
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<br /> . . : ,. � � Nam,e,:of A eri�;, ',..,;, -� � ° D:r;iuer's Lice►ise No ;%;:;..
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<br /> ROBERT DEESE
<br /> D200-762-64-171-0
<br /> RAYMOND BURGHER =B626-730-95-030-0
<br /> DAIKEL SUAREZ . , 5623-160-91-211-0. _ . ._ .
<br /> . CALVIN PERKINS " '
<br /> P625-100-70-324-0�
<br /> TONY BLEVINS B415-810-79-220-0
<br /> This form supercedes any previously submitted letter(s) of authorization.
<br /> This form must contain only the people you want to pull permits in your name. To make changes to this
<br /> form, you must submit a new form. This form will delete and replace any previous authorization form
<br /> and the information contained thereon. f�OC 1�0.
<br /> This authorization will remain in effect until STATE OF
<br /> cancelled in writing by the undersigned �. ``
<br /> license holder. COUNTY OF t S�('plJaGh
<br /> Sworn tp(or affirmed)and subscribed before me this
<br /> �,day of `�('���('� ,20 t.5
<br /> by
<br /> (Printed/Typed me of cen e Holder aking Statement)
<br /> Lic se Holder's Signature RY P BLIC
<br /> ���11NNIINtl�l/% �
<br /> \\����Q�pRA D.q���i���f �s�s t eoe �t�.).—
<br /> ��`0Q;• '�ISS�'•. l o � (n ��a-
<br /> M / � %
<br /> � .�G�;�st T0,?l�.A9�y i (Name ofNotary Typed, Printed,or Stamped)
<br /> =*; d����m� = My Commission expires• C�i(,�L� �D� �D I�
<br /> ' �'�v+�� �';*= Personally Known OR Pr ced Identification
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<br /> i9��:�a BO��e�:Q��
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<br /> ���Ei���STAtE�e�>��� ( ype of Identification Produced)
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