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Triple �rown R.oafing Inc. <br /> 7140 Andre Drive <br /> Zephyrhills, Fl. 33541. <br /> (813) 8�3-7720 <br /> State Lic.iCCC049370 <br /> E-mail: LNaultl963(a�aol.com <br /> Web Site:www.'I�riple-Crawn-Roofing.com <br /> I, ��'�e� �e ��.�.,� ��`� d'�£��� ���U�'e v����b"OC�� � <br /> �Print Name Here} � {Frint Busizzess Name�Iere 1 G <br /> do hereby designate the following individuat{s}as having the autht�rity ta sign sud snbmit appticat�ors aud related documents far <br /> the J�urpose of obtaining building permits under my �� Contcacwr Certificate af Campetency, re£erence # <br /> �C,�Qt.(�1',37l� . I further acknowledge and accept, as a licensed contractor, my resgonsibility, aF:id tiability for each groject <br /> permitted under the author'sty designated an this form which supersedes and repeals alI other previously submitted signature <br /> aut�ority farms, and that my failure tcr assunne and fulfill said duty ma.y be grpunds£or the initiatian cf disciplinary action against <br /> my con#ractc�r's li�ense. <br /> I)ESIGNATED SIGNERS: (I'LEASE PRINT}; <br /> a � r? ,. e <br /> 1.) �' �� �� �a �.: <br /> � � <br /> 2.� 5'�0��-�-�-�.r►�,aSo�U <br /> 3.) <br /> 4.) <br /> 5.) <br /> Dcsignate�i signers may be reqnircti to provide proper identificatian at the request of#he perndt office. The number of <br /> designated sa,gners m�y not eaceed�ve f5). <br /> This original form mu�t be st�bmit#ed far designating signature autharity. Yau must return this 7 orm with the ORIGINAL <br /> na#ary seal�o oar c�ffice. No capies or faxes wilt be accepted. We are ha�rp3`#o provide this scrvic�:;hawever,we reserve ttae <br /> right to suspend this service at any#ime due to its abuse ar misnse. <br /> BY: ,���"5 �a ����� �� � ��w'�y� <br /> {]Printed Name� {Signature) <br /> � <br /> State of F�orida, County af . � Sworn to {or afFirmed) and su6.3cribed before me this <br /> 7-��' day of ...�Gt,t'�� 20_��.._� by �A Il p`�t.L�t.-G d who is ( <br /> � <br /> personally kuo�cvn o m or who has produced of ID}as identification. I� <br /> .�nY'e',�a4 JACQUELINE BOGES <br /> '��c' Commission#FF 15Q422 <br /> t �f �kI <br /> �� � q: Expires December 12,2018 <br /> � ':;;pFp�Q�• BonCadThruTroyFainlnsuranca800-365-701� i <br /> I <br /> Si e ' atary Pubiic te of FIc>rida Print,type,or stamp name ofNatary — <br /> My Com�nission E�ires: ��ePr��- �2r Zol� Notary Seal <br />