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THE ROOFIN <br /> i - <br /> --COMPAi\Y J <br /> OLD FASHIONED SERVICE <br /> CONTRACTOR'S AUTHORIZED SIG EE FORM <br /> Business Name: o rJC y /� O <br /> Owner's Name. /✓(/G /7�/it/ / L�/s�l�,/"l Phone#: 2 %� <br /> Business Address: 56�3,5 k.-le It G/ 6—zl Phone'1:( )-- <br /> City: a�7 2 State Zip:� (F�5 z <br /> Qualifier's(Contractor)Name: <br /> Typc of Contractor: <br /> State Certification it:�[�C / 2�c3�3 PCCLB#: ��r� �J Z 9� J <br /> Email Address: C " csi lc: <br /> STATEMENT <br /> I,the above named qualifying contractor,for the above named business,hereby allot the following person(s)to pull <br /> permits in my absence: <br /> (please print)AUTHORIZED SIGNEE NAME: <br /> i <br /> (please print)AUTHORIZED SIGNEE NAME: �/�,/����_ Af-al`/� <br /> (please print)AUTHORIZED SIGNEE NAME: - ljl/ sv <br /> 1 further certify that the above information is true and correct to the best of my knm [edge. <br /> Signature of Qualifier(Contractor) Print Name <br /> STATE OF FLORIDA <br /> COUNTY OF PINELLAS1 I I t`\ 0n <br /> Subscribed and sworn to before me this I ?J day of �AWV 60 by l j{ I V1 �� bS <br /> ,.aho has produced Florida Driver's License# as identification. <br /> G' $y�ry� Notary Public State of Florida r� <br /> Becky Woodall ignature <br /> My Comrnl'ssion GG 196217 <br /> Expiresb3l14/2022 L raw <br /> Notary Publi (type/print) <br /> (seal above) <br /> Commission Number <br />