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City of Oldsmar Contractor Authorization to Sign Permits

  1. _________________________________________

    Date

  2. _________________________________________

    Print Name of Qualifier

  3. _________________________________________

    Qualifier's Company Name

  4. _________________________________________

    Email

  5. _________________________________________

    Company Address

  6. _________________________________________

    Qualifier's License #

  7. SIGNATURE OF CERTIFIED CONTRACTOR MUST BE NOTARIZED. THE FOLLOWING INDIVIDUALS FROM THE ABOVE FIRM ARE AUTHORIZED TO SIGN PERMITS FOR MY COMPANY IN THE CITY OF OLDSMAR:

  8. _________________________________________

    Print Individual Name

  9. _________________________________________

    Sign Individual Name

  10. _________________________________________

    Print Individual Name

  11. _________________________________________

    Sign Individual Name

  12. _________________________________________

    Print Individual Name

  13. _________________________________________

    Sign Individual Name

  14. Authorization for the above individuals to sign for permits for my company will remain in effect until further notification from this company is provided to The City of Oldsmar. I am aware that if any changes are made by my company regarding the above information, it is my responsibility to notify The City of Oldsmar.

    Signature of Certified Contractor ____________________________________________

  15. STATE OF FLORIDA

    COUNTY OF _______________________________

  16. Sworn to and subscribed before me this ___________ day of _________________, 20______.

    By _______________________________________.

  17. Notary Public, State of Florida (Print, type or stamp name)

    ____________________________________________

  18. Seal:

  19. Identification

  20. _________________________________________

    Type of identification produced: Include ID #

  21. Leave This Blank: