14-15275 - Laserfiche WebLink

Browse Search

: :._ , AUTHORIZED AGENT _ - AFFIDAVIT I �2'� ��1V10(� hereby grant authorization to.. S"�lU e, NGll.l�f'OC�LI (Contractor) (Authorized Agent)_ to act in my behalf with the Hernando County Development Department while conducting activities related to obtaining permits. These activities specifically include signing all documents requiring signature of"contractor". , . �� Q 1�,1�i =is to be considered an agent of my business and (Authorized Agent) therefore the signature of said agent is binding and causes me to assume all responsibilities connected to or associated with the signature as they may relate to my contracting business. I t��f �(��'1� relieve the Hernando County Development of, . (Contractor) and agree to hold the Hernando County Development Department harmless from, any and all responsibility, claims or other actions arising from or related to the DepartmenYs acceptance oF the above agent's signature for permit-related activities. I,further understand that it is my sole responsibility to grant and terminate any such authorization and to ensure that the Department rece' e timely no ic of any such grant or termination. 1 �n.e � o �\`�2.>>v.��A i ure of Contractor Signature of Agent C � oas 2, �-{�R�`�1��I � =State Certification or Registration Number County Certification Number(if applicable) **PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED'* Notary for Contractor's Signature: Notary for AgenYs Signature: State of � County of � � O State of �' L County of . e`�Y1q��V The fore ing was acknowledged before me this 2 The foregoin was acknowledged before me this �'f'"� d of Dl ,by day of � �/ , by�.�N��roc k i� � p ,yyhp izparcnna��gyyn who person Ily known to me,or to me,or who produced as who produced ` � as identification. Identification. .,�0 q� . �..� ota P�tt�� nature pENNY F�RNANDQ tary Public Signature ��a��pr,,4 TERRI L.STOKES '�'� �'' MY COMMISSION#FF 0600G0 `' �-- •'`� � ' �; . :,: _ ;;: - `�-; No4ary Publlc-Siate ot Florida �:, ;;; EXPIRES:October3,2017 =• •"e M Comm.Explres Aup 27,2016 Print, °� • Print,Type,or Stamp Name of N �,,� �,��;.�` CommissloR#EE 830572 � �'��°��`� � Bo ded h ational Notary Assn. ' � *The originaf of this affidavit should be kept in the possession of the above designated"Aut • ` � need only be produced to Hernando County when signing documents in the presence of a permit representative. When you sign a permit application be prepared to produce this affidavit,it will be copied and placed in the appropriate permit application.* x"The Departn:ent,at its discretion,may require a contractor or license-/rolder to personally apply for or obtain a building permit notwillrstanding any aut/iorizntion a!lowing a�:otlier perso�r to apply for or obtain any permit on be/rqlf of a contractor,7ualifier,or license-/�older. , Revised 08/21/00 contauth.sop _... I —