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. �a�' �e <br /> �� � � <br /> S�abee AC and Heat, INC. <br /> 8402 Donal Street Port Richey, FL 34668 <br /> �� `� <br /> Phone: 1 (855) 833-2665 (COOL) <br /> �an Do� <br /> AUTHORIZATION FORM <br /> Date: <br /> Name of license holder: �. �, <br /> County Certificate# or State License # C�1�,��( ��.,3 <br /> The following person(s) are authorized to sign for permits for the above referenced <br /> license holder. All person(s) authorized to sign must produce a valid Driver's License <br /> with photo or Government issued photo ID card with this application. This Authorization <br /> is for Permit Applications only. <br /> NAME S : PLEASE PRIN � AT RELATIONSHIP <br /> Q� eL <br /> �.� � <br /> Authorization forms are good 12 months of dated form. <br /> (Unless otherwise specified if less than 12 months � <br /> Signature of License Holder or Authorized Agent <br /> STATE OF '�Q(j(�C� <br /> COUNTY OF �(�,�a <br /> I HEREBY CERTIFY that the foregoing instrument was acknowledged before me this <br /> ��' day of �(J��,,yr�,be,�/ , 20 i a by <br /> who is personally known to me or who has produced <br /> �" as identification. <br /> � <br /> Sign of tary Public <br /> lNRY FU6 <br /> z� ,<<, JOFIN J.AARON <br /> * � * MY C(MIMISSION A DD 977675 <br /> EXPIRES.April4,2014 <br /> s�"'��r F��a�°� '�oMed Thru Budget Notary Senlces <br /> Prmt Type, or Stamp Name of Notary <br />