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� , , , AUTHORIZED AGENT AFFIDAVIT . , � fy(� I��/s'��CfyUl�hereby grant authorization to�/�� � (Contractor) (Authonzed Agent) to act in my behalf with the Hernando County Building Division while conducting activities related to obtaining permits. These activities specifically include signing all documents requiring signature of"contractor". .�_ , � is to be considered an agent of my business and (Authorized A ent) therefore the signature of said agent is binding and causes me to assume all responsibilities connected to or associated with the signature as they may relate to my contracting business. I ��L '�jSGdiWQ�/'U�elieve the Hernando County Building of, (Contractor) and agree to hold the Hernando County Building Division harmless from, any and all responsibility, claims or other actions arising from or related to the Division's acceptance of the above agenYs signature for permit-related activities. I further understand that it is my sole responsibility to grant and terminate any such authorization and to ensure that the Division eive timely notice of any such gr t or termination. ' Signature of Contractor / ignature �Agent �e �Q.�-� � ��/ State Certification or Registration Number , County Certification Number (if applicable) *'PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED** Notary for Contractor's Signature: Notary for AgenYs Signature: State of � County of 1 /G�TiY j�� State of � County of ��1�.(�l�-G ) The foregoing was acknowledged before me this � The foregoing was acknowledged before me this ' � d of � ✓" / ! b da of`�l�P�:/�iiL11.✓t�� by�OJ7�/ � ,who is personally known o i ersona nown o me r o me, r who produced as who produ d / as en ificatio . � I n tfic on / � ��,-.� � Notary Public Sign t e =eR'1 '= ' Notary Public Sig ,��:"•• •-,, • :�. �';;: MY CONfMISSION A FF 238396 ;�. ,� MY COA�h�ISSION�FF 238396 =��. �a: EXPIRES:June 8,2019 :y:, ;° EXpIRES:June e,2019 7�Rf��' Bonded Thru Motary Public Undervrtiters �1,'""'Q.p`�� Banded ihru Notary Public Undervrriters Print,Type,or Stamp N "�'�°"' Print,Type,or Stamp 'The original of this affidavit should be kept in the possession of the above designated"Authorized AgenY'. This affidavit need only be produced to Hernando County when signing documents in the presence of a permit representative. When you sign a permit application be prepared to produce this affidavit, it will be copied and placed in the appropriate permit application* *''�Tlre Drvisioir,at its discretion,ueay require a contrnctor or lice�rse-ho(der to personally apply for or obtain a buildrng periuit i irorivitl�sta�tdiirg afey audeorization aUorvr�:g another person to apply fo�•or obtain any peru:it at behalf of a contractor,qualifter,or license-ho/der. ' Revised 10/2015 contauth.sop / � /