Laserfiche WebLink
�'ea�' �e <br /> � i"� �� � Seabee AC & He <br /> at, INC. <br /> � _ "� ��� � 7924 Rutillio Court New Port Riche FL 34653 <br /> Y, <br /> � . . 1 � Phone: 1 (855) 833-2665 (COOL) Fax: (727) 835-0111 <br /> ��� � <br /> �,� <br /> �� ,� <br /> �a� I�o ` <br /> AUTHORIZATION FORM <br /> Date: /� "�'_C_�_m��r .j � �!�1 � <br /> , <br /> Name of License Holder: Rock A Masse <br /> County Certificate # or State License #: CAC 1815493 <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 issues photo ID card with this application. This Authorization <br /> is for Permit Applications only. <br /> NAME(S):PLEASE PRINT SI(' ATURES RELATIONSHIP <br /> Zachary Harris ___ Employee <br /> Authorization forms are good for 12 months of dated form. <br /> (Unless o erwise specified if less than 12 months � <br /> X _ �ii� l � <br /> Signature of License ld r or Authorized Agent <br /> STATE OF - � �� <br /> COUNTY OF � �� <br /> I HEREBY CERTIFY that the foregoing instrument was acknowledged before me this <br /> 5} <br /> �-day of `� r , 2p�by .�vC k � c � <br /> � �1 ��C\.� <br /> who is ersonally known to m or who has produced <br /> � as <br /> identifi at'on. <br /> ' I <br /> i` <br /> � <br /> Si�n ur of N �� a�t}��a�blic � <br /> . ^ JOHN J.AqqON <br /> * h�Y COMMISSION!i DD 977675 <br /> N,9T ap EXPIRES:April 4,20f 4 <br /> � <br /> Print, Type, or Stamp Name of Notary m�s <br />