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<br />AUTHORIZED AGENT <br />AFFIDAVIT <br /> <br />l <br />II <br /> <br />I hfevl." C~{Ur:l hereby grant authorization to J.Li,/;;/v(' t1l?;C,Ty1C,-" <br />(Contractor) I (Authorizect-lAgent) <br />to act in my behalf with the Hernando County Development Department while conducting <br />activities related to obtaining permits. These activities speCifically include signing all dccL4ments <br />requiring signature of "contractor". <br /> <br />'. ;)&1 j {i" i'."- is to be considered an agent of my business and <br />(Authorized . gent) <br />therefore the signature of said agent is binding and causes me to assume all responsibilities <br />connected to or associated with the signature as they may relate to my contracting business. <br /> <br />51e'J/r!- C:;'fl;>f;r] relieve the Hernando County Development of, <br />(Contractor) <br />and agree to hold the Hernando County Development Department harmless from, any and all <br />responsibility, claims or other actions arising from or related to the Department's acceptance of <br />the above agent's signature for permit-related activities. I further understand that it is my sole <br />responsibility to grant and terminate any such authorization and. tPJ8. risure t~ Department <br />receives timely notice of any such grant or termination. /1'1/ A ;:;;~, /1' ,/ // <br /> <br />-~ .// r //~~It!,//'/t//Z~/C/L ~ <br />Sign ture of Contractor / /_ v Signature of .!\.,ge:1t ..~;: <br />'~- ;.... <br /> <br /> <br />.~e (' r:7 ~ &"C' 7 / <br />State Certification or Registration Number <br /> <br />County CertifiC:3tion Number (if applicable) <br /> <br />....PLE:ASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED** <br /> <br />Notary for Contractor's Signature: <br /> <br />Notary for Agent's Signature: <br /> <br />---7 _'! <br />State of .."'- L /1 <br /> <br />.''; <br />County of /~-." '. i~~"/~'i" ~~,..,~."""."/'~ <br /> <br />Slate of C~ r <br /> <br />County of ,--... <br /> <br />,r,:"(. ,:.." f;[-/ _,~,- .' <br /> <br />j <br /> <br />The foregoing was acknowledged qefor~ rpe this ,~ ,; <br />day of-">'/f /;;: '- , ,J\ I. L .5 ,by <br />;:-J-; , " -- '-: ,-,,9 /1 . who is personally known <br />~.or wh9.-produced as <br />:d'ef1tifi~h9f / <br /> <br />.-b(~U.2c c ,~U; :)0 L / (S'7~ UJ:.~l;r <br /> <br />NotarY Public Signature ' <br /> <br />wh1J'Q(6<1.~' <br />Identilieati(n <br />..dr-,j' ((I/{i~;;'. I <br />...' - '- " - <br />Not<;riy Public Signature' . <br /> <br />,/ - <br /> <br />../", ../ <br />~. ~.,_ '_:; <N:--Y- <br /> <br />'/ <br /> <br />.-:.~:t~::'~)' Shaunesc:v Owens ,..Ill'", <br />, "....r~, -, .' OJ\"( Ps'" <br />pri~f-r~:f~ ~~~111 flf lolUW::Ii'fII\ :)(PIRE~ Prinf:~~:~ ~,,~WleI3It~s . <br />~~.~:.;: 'teDiilary 23;2lb'6 c~: .. ~ - -~# "OD07!5;o 'XPlRES <br />"'~-%';'.A.*,~ JONOEDTHRUTROYFA:NINSURANCE.;NC "~"''''~o/ February 23 2806 - <br />. The ~'~;~inal of this affidavit should be kept in the possession of the ~b~~e de~?g~~rJ~Tt<Jl:UW;~~ ~ent". This <br />3~-fidavit need only be produced to Hernando County when signing documents in the presence of a permit <br />representative. When you sign a permit application be prepared to produce this affidavit, it will be copied and placed <br />in the appropriate permit application_* <br /> <br />Revised 11/08/99 <br /> <br />contauth.sop <br />