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i r <br /> Permit Agent Authorization <br /> ': l.t Ho er' Na AT'Oltt a Name ', of I±Icense <br /> hereby authorize'the following to act as my-agent(s) in obtaining permits in the City of Zephyrhills, Florida. <br /> PermitAgent • Last Name <br /> MCL(Atan <br /> his is m ersedes arl, uio s s b��d e s+ of a�u,�i�� -a i_orli <br /> This form mustcontain only the people you want to pull permits`ir your name.To make'charges to this form,you must submit a new <br /> form:This form will delete and replace.anv previous authorization form and the informati n contained thereon. . <br /> License Holder's Signature:-' - Date: <br /> State of 0 orvo,,,, <br /> C� <br /> County of: <br /> Before me,personally appeared, C who produced <br /> as identification or i personally known toe,a_ Zw affirm and subscribed before <br /> me this day of 20 <br /> A&Seal S gn to of No ublic <br /> or <br /> Stomp <br /> 1 ame o T f Votary ,panted or stamped <br /> ;ems•t Notary,F3Ubljc State of Florida _ 1 <br /> Brandy Mane Scadett My Commission Expir s: <br /> +„ My Commission GG 137903 <br /> Expires 12l17r2021 <br /> HCFLGov.net <br />