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<br /> AR �� HtTEG�"�.1R�L S�-1E��1" hr1ETRiL P'�OFES� IOl�4AL5 •
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<br /> I, ��'�-� � J�1i�is of �� �a�hS /tidc��t-���R �'"f�e.e�" ����. -�lx�,
<br /> � Contractpr/Qualifier's Name Florida Shate Corporation,L'uru Partnership Compaz�y or Trademark Name
<br /> hereby I ant authorizatian to � Y f`� c"_' to act in my behalf with The City of Broaksville as
<br /> Authorized A ent's Name
<br /> 0 AC'TIl�'G AG�NI'-Nd RESTRICTIONS or L�ACTZNG AGENT FOR PERMIT#: (only}
<br /> for the�Building Division. These actzvities sgecifically include signing all documents requiring signature of"cantracta�"and is to be
<br /> considered an agent of my business, and therefore,the signature of said agent is binding and causes me to a$sume all responsibilities
<br /> conmect�ed to or associated with the signature as they may relate to rny contracting business. As said contractor,I also agree ta.relieve
<br /> the Cit� of Brooksville Building Division from, any and aIl responsibility, cIaims or other actions arising from or related to the
<br /> Buitdin'g Division's acceptance of the above agent's signature for permit-related activities. I further understand tha.t it is my sole
<br /> responsibility to grant and tennin�tte any such authoriza#ian and to ensure that the Building Division receives timely notice of any such
<br /> $f3t1�Of,�j�8LII11ri1t1QII.
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<br /> Si of Contrae#orJt�ualiSer's Name Signatune a Agent
<br /> � C �C 1 �� �� .� �
<br /> State Certification or Registrstion Number
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<br /> **PI..EASE NOTE: BO'T�I SIGNATURES MIjST BE NOTARIZED"¢
<br /> Notarv or Contractor 3ieuature
<br /> State of��lorida County of f�/t�n a�/l0
<br /> The fore�omg was acknowiedged before rne this � � day af Nd+''', ,24I6,by_ ��'1"� �� ,�I��f
<br /> 0 1 knawn to me o wha produced as idea�catiou.
<br /> II _ �
<br /> ( � 1 N4TARY STAMP: �,t�Y'A;�:;�., •'..`_ �oriN�Ur,NS
<br /> � ;�,o� ,,; Noia�y Pubf�c-State af ftOtiG�
<br /> ` Notary x ignuture � _ '� • - Comm�ssion#FF 983274
<br /> � ��` V���
<br /> '-�. �4 `�`: M y C o m m.Ex pires ARr 18,2020
<br /> � ot for A A ent �'��;;;+;��� gonded through Nationai Notary Assn.
<br /> State of Florida County of - ..�.�*►��=«-.�. . _, --.::�'•�
<br /> ,I _
<br /> 'The for�I aiffg was acknowledged before me this �� day of ���''• 2016,by !v � a k �P i 01 E j
<br /> .a�rbo is p�I anallv knawn to me or who produced _ _ i � tification.
<br /> I4 �\�IYF�R�i� JQNNJONNS
<br /> �� , �4, Notary PubUc-State ol florid�
<br /> NOTARY STAMP: ', , •s Commlt�ion+M FF 9t327�
<br /> I� Notary c S` hue !►ty C+o�lilli�tpE�ii Apt ti,2020
<br /> �n IlOfldld*"'�w�.lqdO�qFNpqt��iii. '�
<br /> *?7te original of this a,�'idavit should he kept in the possession af the abave designated"AuthariZerl AgenP: T7tis uffiduvit need rmty hL ptnduced
<br /> to the G'iiy ojBrooksville Building Divis+ian when signing dacumemts irr the preserrce of a perrtat represemative, Wl:en you sign a permit
<br /> at'
<br /> appl�c�on be prepmed to produce this affidavit,it will be copied and placed with ihe appropriate per»ut application'"
<br /> 3'*The�ui�ng Division,at its�scretiar�,rr�ay require a cantractar or license-hvlder to persvrratly aFFjY.far vr ohtuin u huildang pe+'mit
<br /> not►vithstanding any authorization allmving anMher person to applp for ar obtaiit arry permit on behalJvf a cvntraetar,qualiftc�,or licens�
<br /> hoJder:
<br /> Rev.12/2013
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