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City of Oldsmar Contractor Authorization to Sign Permits

  1. ____________________________________________

    Date

  2. __________________________________________________

    Print Name of Qualifier

  3. ____________________________________________________________

    Qualifiers 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. Commission No: ______________________________

  19. Identification

  20. _________________________________

    Type of identification produced:

  21. Leave This Blank: