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/ <br /> , -, - -� . <br /> �, <br /> � AUTHORIZED AGENT � <br /> , <br /> AFFIDAVIT <br /> I �LL I�ISQ.wV Q%i'Ul�iereby grant authorization to � ', r:G �1�`Z <br /> (Contractor) (Authori ed Agent) <br /> to act in my behalf with the Hernando County Building Division while conducting activities related <br /> to obtaining permits. These activities specifically include signing all documents requiring signature <br /> of"contractor". <br /> �� e<�� is to be considered an agent of my business and <br /> (Authorize Agent) <br /> therefore the signature of said agent is binding and causes me to assume all responsibilities <br /> connected to or associ ted with t e si nature as they may relate to my contracting business. <br /> I �e� �° l/'G�"u'/G�l ieve the H <br /> � l�t ernando County Building of, <br /> (Contractor) <br /> and agree to hold the Hernando County Building Division harmless from, any and all responsibility, <br /> claims or other actions arising from or related to the Division's acceptance of the above agent's <br /> ��- signature for permit-related activities. I further understand that it is my sole responsibility to grant <br /> and terminate any such authorization and to ensure that the Divisi re ' e timely otice of any <br /> �' such grant or te inatio . <br /> � <br /> Si a re ontractor Signat, e' gent I <br /> C'� �.�' �d <br /> State rtification or Registration Number <br /> County Certification Number(if applicable) <br /> '"PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED** ' <br /> Notary for Contractor's Signature: Notary for AgenYs Signature: <br /> _ ^ <br /> State of_�i _ County of / �2i1 �C State of. County of ��j�-(jV�l.l�'� <br /> The foregoin was acknowledged before me this The fore oi g was acknowledged before me this 1� <br /> _ day of ,��,— �� day of <br /> c o is personally known; wh is ersonall known to e,,or <br /> to m , ho produ d who p ed as <br /> tio .� icati <br /> � .�,����, i <br /> � �rs�'�o�.., �-Ii;ROPJt�i.STJE/1N <br /> , ```�`_..�__... _ . <br /> N ary Pub ic r,��{t�Yavc, SHAROid M.STJEAN Notary ic Signa : ' fi= "��` ` `°`� ° ' " <br /> .a. <br /> z;;?' •�: MY COAiMISSION§FF 238396 .���. �Qa EXt'IRES:June 8,2019 <br /> �,="�;J�,.P; EXPIRES:June 8,2019 'o;'or n�•'�r,o�sedihru NotaryPub!icUntlerwriters <br /> �v <br /> Print,Type,or ta_��m� Print,Type,or Stamp Name of Notary <br /> "The original of this affidavit should be kept in th possession of the above designated"Aut'horized AgenY'. This affidavit <br /> need only be produced to Hernando County when igning documents in the presence of a permit representative. When you <br /> sign a permit application be prepared to produce this affidavit, it will be copied and placed in the appropriate permit <br /> application.* � <br /> �1 <br /> ''�*T/ie Divisio�r,at its discretion,niay require a caitrnctor or liceuse-holder to persouaUy npply for or ol�taru a buildii�g pernrit <br /> notwidrstandi��g nuy atrthorizatiou alloiving anoN:er persoie to apply for a�obtaii:a►:y per�irit on behalf of a catb�actor,qualifrer,or <br /> lice�:se-/:o[der. <br /> Revised 10/2015 contauth.sop <br /> \ J <br /> / <br /> .� <br /> \ <br />