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AUTHORIZED AGENT <br /> AFFIDAVIT <br /> I��T��D irt1.�OF/�Kereby grant authorization to G L� s�f�l�i'7�/ <br /> (Contractor) (Aut orized Agent) <br /> to act in my behalf with the Hernando County Development Department while conducting activities <br /> related to obtaining permits. These activities specifically include signing all documents requiring <br /> signature of"contractor". <br /> / <br /> �'G Sh'�R : is to be considered an agent of my business and <br /> ( uthorized Agent) <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 /> I�(�l�b �.� d1�S0 e�iev� the Hemardo County �ev���pr�ent o{, <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 the <br /> above agenYs signature for permit-related activities. I further understand that it is my sole <br /> res i ity to grant and terminate ny such authorization and to ensure that the Department <br /> r eives ti; ely notic f any ant or termination. <br /> . <br /> Signature of ntractor ignature of Agent <br /> � <br /> � "' �p�i ,�� <br /> e N t e Certification or Registration Number <br /> = LL ^ <br /> N O � <br /> Q V Of <br /> G- m °' O <br /> Q y � � nty Certification Number(if applicable) <br /> LL � 'n c <br /> _ ac o <br /> W a E � "PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED" <br /> � T E E <br /> o � �o ry for Contractor's Signature: Notary for AgenYs Signature: <br /> z '' <br /> � �p � <br /> `�N�u�u� �,�il' i(,?!�r�... ���CU � <br /> ,,.��c ro$ta of County of State of� County of <br /> :�° «• '�Ei: <br /> =� f�q foregoing was acknowledged before me this �:'���' The foregoing was acknowledged before me thi <br /> ��°h . s�;�y�of _, �l�\� ,by d-•cf�� , p� b� , <br /> �'•���,,,������i�i.. � r� ,who is personally known who is pe�y known to me <br /> �e,orwhoproduced � ,��..�L� L�c_�;�5� as w opr duced �— � C as <br /> identification. 1 Id ti atiQL�. <br /> �� <br /> Notary ,ubli nature Notary blic Signature ' � , , <br /> ` _ _ rr;; �-� � _�` _ <br /> J � f `i � <br /> � �'� �b <br /> C /� c <br /> ��\V����L.✓ � � \ ��..�� �. . � ,_:� i r�uri�,i. s� <br /> �` <br /> Print,Type,or Stamp Name of Notary Print,Type,or Stamp Name o$Notary , � ��;� r,r ,�; t . ,, i � ;��q & <br /> 'The original of this affidavit should be kept in the possession of the above designated"A6thoriz�d 4�c�e�t", ThES affid,�vif�;; � <br /> ��.�. , ,.: <br /> need only be produced to Hernando County when signing documents in the presence of a::permit=Fepres�r�t�i�y���ewyo� ,.;�e �,= :y <br /> sign a permit application be prepared to produce this affidavit, it will be copied and placed in the appropriate permit <br /> application.' <br /> �'''The Depnrtment,nt its discretion,nray require a coirtractor or license-ho[der to personally app[y for or obfain n b�rilding per��iit <br /> notwithstanding any nuthorizntion allowing another person to npply for or o6tain any permit on belrn/f of a contrnctor,ryunlifrer,or <br /> [icense-holder. <br /> Revised 08l21/00 contauth.sop <br />