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<br />
<br />AUTHORIZED AGENT
<br />AFFIDAVIT
<br />
<br />I ,4If" O/Vr> hereby grant authorization to /);~,&! t ;{;~T/J r., ~
<br />(Contractor) (Authorizect1Agent)
<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 />j'. /
<br />.. ~'{Jf( J:~" ;/1"
<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 />v / /.J
<br />Stele f.;;<7/V.'e/7
<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 70': nsure ~ Departr1)ent
<br />receives timely notice of any such grant or termination. /, //1 /l / /
<br />
<br />>?: /f!'t :z" / /~t/ 4t . 'VL -..
<br />81 n ture of Contractor i __ Signature of ,t\gent
<br />~
<br />
<br />is to be considered an agent of my business and
<br />
<br />relieve the Hernando County Development of,
<br />
<br />
<br />
<br />.:::;(' r: (~;~ UN> 7 /
<br />State Certification or Registration Number
<br />
<br />County Certification Number (if applicable)
<br />
<br />-PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZEO-
<br />
<br />Notary for Contractor's Signature:
<br />
<br />Notary for Agent's Signature:
<br />
<br />.---; J
<br />State ofL L-1..-f
<br />
<br />County Ofi~ ,
<br />
<br />~'-; r/'" ..>~ L~:i.,. (_~ /--:'
<br />
<br />-
<br />The foregoing was acknowledged before Te this -7'" ,.
<br />day of ~/,,/.1 /L<'-I . ,;.;. C~ . by
<br />-~, /' /. '" ,>':1 /; . who is personally known
<br />~or whq-produced as
<br />id9ntlfiiGt~?-'~
<br />,0~ r/ l~
<br />~ ( [t,. I.,':,"'" _ , /_'-:-"?',...(:-.~,_, __
<br />--i--'C.f.... U-,tui~,-I ,-. ~l;T
<br />NotarY Public Signature . /
<br />,/
<br />
<br />l/ - , . .
<br />Slate ofee H County of ,c'--f- 'ii!:!.. y/""(/j.(.r:'
<br />I
<br />.-
<br />The foreg.~"E"wa~ acknowledg~ bef~r~me this J I
<br />dal( of ... 11../ i / . -I r (/ :5. by
<br />/., 1'(/ YC-j' - /! who is personally known to me. or
<br />wtm-pt:Oau~, J - ~ as
<br />Ident~Caoon. /
<br />
<br />- '~..I../'~-,/ .1.. /, v.(_. tl,....~... / ...: :.-./. 1,../:,. J
<br />.~ - . C r U:'j/~-L..'; (~'.....:;.-:pt~
<br />Not;;ny Public Signature ij'
<br />" '.~
<br />
<br />...~;':lpp~... Shaunessy Owens "011"",
<br />'~~..... '. . -;;;'''''ep''
<br />Prirr.t\:1 :~~ ~~~ ~f 1oIHW::l;>flO cll~l~t~ Prinf:~~. :~~.bi=.o ~lIIte."'~s .
<br />~~'. :,,~ rebniary 23;2lit6 = : ; = IVrn:.0J\4_aN'# ODe71 ;:
<br />'-.::to';",*,"" clONOEDTHRUTROYFAlNINSURANCE.;NC '~;~"",,""~';- i=@bruary23285}G6.XPIRES
<br />'..""., . . . . ,.of..f,;'t. 89NDEDtH ,U
<br />. The original of this affidaVit snould be kept In the possession of the above deslgnate~~liW!~Agent". This
<br />affidavit need only be produced to Hernando County when signing documents in the presence of a permit
<br />;'epresentative. 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
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