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- ---- -- �- ..L. r.�_'� <br /> Bldg.P'ermtt Application Nu.: <br /> (To be Cotttpleted by Permit Repreientntivaa <br /> SUB-GQNTRACTCIR AFFIDAVI7 <br /> GATE: �/ J,I/� � <br /> TQ�"+HOM IT M,�iY CONCERN: <br /> i. -�..2.�t�4�_ (�C9,Cr�.S <br /> dib;� o ett �r : � __r___. , <br /> �icenae Number:��A'dO•�'��O ,wiii be the�� �e C.,� Q�C'� � <br /> {�xample: Electrical, Mechanic�i, <br /> contractnr fvr this permit aPPlication. The job address <br /> Rl�mbii�g, Roo�ing, Gas, Etc.) <br /> is� �0 � � (` ��� <br /> SignatUre at License Holder ar Autl�oriz�d Agent , <br /> STATE OF FLORIDA <br /> COUNTY Q�•�n1�Z,�a� <br /> �,� <br /> � HEREEY CERTIFY th�t the f�regoing instrument was ackn wiedge� b�f�re m�this / $ ` _day c�f <br /> ' , 201'�,_, �Y�l.d� Ct-Q � � W�'s pet6G��1fy <br /> known o me or who has prod�ced__ _as icier,tificefinn_ �"�— <br /> ,.----- '1' <br /> .r /1�1I3�-� _ �..-- <br /> S' �ature of No Puolie <br /> Prir.t, 7ype, or Stamp Nam�nf �Jatary <br /> �OTARY PtiY3LIGSTATE OF FLORIDA <br /> ;�;; Darlene Ford <br /> `-Commission#DD905245 <br /> ,, Expires: AUG.07,2013 <br /> QONDED THRU ATLi'vTIC BO\'pI:VG CO.,INC. <br /> y�n,a:��to Ca.Oav Dept., T8b Prvv�danc.�s Bou�evard.&uoksvitJe,Flvrrde 34641 ���`�'i��� �FeY��3$2J7�4-�Ff�6 <br /> � ' <br /> Rev,UJr03.�G2 <br /> E:iwtxiuru�p�nititslsn:lpp.wrd <br /> TC�Tk� F'.�� <br />