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<br />AUTHORIZED AGENT
<br />AFFIDA VJT
<br />
<br />II
<br />
<br />
<br />1.
<br />
<br />I 4/,'(1 (Jrler-J hereby grant authorization to II:"./' u tv:;q "'r. -
<br />(Contractor) . (~~~hOri;~;~9~~t)
<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 documents
<br />requiring signature of "contractor".
<br />
<br />~i;;o~~i;~~ is to be considered an agent of my business and
<br />
<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 />,// It /)
<br />~ ~I./~ L-n/72~e,r}
<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 gr~nt and terminate any such a~th~rization and... ti9' nsur~.th ..... Department
<br />receives timely notice of any such grant or termination. . " /
<br />.r I...'
<br />;" in / /' // / /
<br />" /'/;!' ~/,-' ,I.~ /l ., / / _" ,,"} ~
<br />,~ /2 f //tt/IJ'<r/ /~ /Lv:.~/L~ -'
<br />ture of Contractor I)' Sigr.at.J're of Agent /~/
<br />
<br />relieve the Hernando County Development of,
<br />
<br />
<br />i Sign
<br />~
<br />
<br />L..{J/:r~ .r-.:.-,,/, 7./
<br />, / , ,'''''' V l./
<br />State Certification or Registration Number
<br />
<br />-------
<br />
<br />County Certification 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 />C7 ..-)
<br />State of ; '--' I /
<br />
<br />;,
<br />County of i'-r' .
<br />
<br />, '
<br />.-: ~:~ /7,c-'// !:~\., .'''~''''r'/--
<br />
<br />---, "':
<br />Slate of .L- L ,-
<br />
<br />County of
<br />
<br />i
<br />1';'-",'
<br />
<br />'.I' ,/,:/... 1,1 ~ f.,.( :.oj' .> /
<br />
<br />-'
<br />
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<br />The foregoing_was acknowledges! befor~me this;;r'
<br />daX of '--If tf,ci . , ,-' / () :5, by
<br />i'-' i 4:'., .~,-' ,1 who is personally known to me. or
<br />who-!;l(oau~, .' ~as
<br />tdentT6a,~n, ./
<br />
<br />_ .! :L; /'( , i :I/L.~ __/'-;; .~, l....:/....t /~ L~' ::~/;..-~..--
<br />~., .~. '-.- ;.- /'"
<br />Not;;rry Public Signature
<br />
<br />The fore.going w,as,acknowledgedbefO(e,pe this ,~'
<br />day of _ir~/,' / L ,'_1. ,?<.' C -' ,by
<br />S:v / (. ,. - ,...,9 /-"' . who is personally known
<br />~or whq..produced ,- as
<br />:d'ent!f!~.."t!!.r..y( .. . . . ....--/
<br />\pr~;/_., .. .. .. -, .~. -l.-~</ - ,. /. .'-; ~_ ~
<br />-------+--'.C U_L L L .~. Cd- _/C' :.. I -' " /, '-""- i.J, ;.7
<br />NotarY Public Signature !
<br />
<br />'J
<br />
<br />1,111'1, ....h "wen"
<br />.......~~~!'sf'~~~... :;; aunessy '.-J ~,: . ,-"'rr.yIW~/,
<br />pri~t1~ltt 's'tMrli9~ ~f ~~i'f "J'J'IRE:; prin!'':;~:l. :~ ~J~{JJ~W\III$W~S ,
<br />~~"~'~~ r-ebruary i3;29l1'6 '3:. :_= M.fi5lBN'# DD071StiI SXPlRES
<br />'.1.iip,...;;.,l{;,.,.- oONOED THRU TROY FAlN INSURANCE, IN(, '..;,......~}: r-ebruary 23 2806
<br />. The',~f~;~inal of this affidavit should be kept in the possession of th~ ~b~~e de~ig';i~W~T~UW:lI'j~lI'fgent". This
<br />2;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 11108/99
<br />
<br />comauth.soP
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