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State Certified—Licensed—Insured <br /> IVIAY <br /> GCG061190,CMC053778, CFC057763, <br /> CVC56974 <br /> C <br /> 4951 Adamo Drive,Suite 232,Tampa,FL <br /> 33605 ,I�;OMME <br /> • • of • • <br /> (Castor's-Name] {Contractor's license_#,} �6«9 <br /> herebyauthorize thefollowing to actas my agent(s)in obtaining permits in, County,Florida. <br /> PermitAgent First and Last Name Driver"s, License <br /> MosUaA P 2) — <br /> This.forin AMP elrsedes"any`preciously submitted [etteir{5) of:;auttiorization <br /> This form must contain onlythe people you wantto rmitsm our name.To make changestothisform,you mustsubmita new <br /> form.This form will delete and re lace an 'e usauthi rizataon form and the information contained thereon. <br /> Q v <br /> Contractor's Signature: Date: <br /> State of.• <br /> County of: <br /> CS <br /> Before me,personally app ared, 0 L A-g o D A-pl— —,who produced <br /> �i —ap identification or is personally known to me,a dv o did affirm and subscribed before <br /> me this day of ,202 <br /> 9�<S�atu of otaryPubli <br /> got yasso David V.Siegel Name of Notary Typed, pr ted or stamped <br /> NOTARY PUBLIC <br /> a -STATE OF FLORIDA My Commission Expires: <br /> Comm#GG156396 <br /> SINCE 1 Expires 10/30/2021 <br />