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City of Oldsmar Contractor Authorization to Sign Permits

2. _________________________________________
   Date

   Date

3. _________________________________________
   Print Name of Qualifier

   Print Name of Qualifier

5. _________________________________________
   Qualifier's Company Name

   Qualifier's Company Name

6. _________________________________________
   Email

   Email

8. _________________________________________
   Company Address

   Company Address

9. _________________________________________
   Qualifier's License #

   Qualifier's License #

11. 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:

13. _________________________________________
    Print Individual Name

    Print Individual Name

14. _________________________________________
    Sign Individual Name

    Sign Individual Name

16. _________________________________________
    Print Individual Name

    Print Individual Name

17. _________________________________________
    Sign Individual Name

    Sign Individual Name

19. _________________________________________
    Print Individual Name

    Print Individual Name

20. _________________________________________
    Sign Individual Name

    Sign Individual Name

22. 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 ____________________________________________

    Signature of Certified Contractor ____________________________________________

24. STATE OF FLORIDA
    COUNTY OF _______________________________

    COUNTY OF _______________________________

26. Sworn to and subscribed before me this ___________ day of _________________, 20______.
    By _______________________________________.

    By _______________________________________.

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

    ____________________________________________

29. Seal:

31. Identification

    1. Personally known

    1. Produced Identification

32. _________________________________________
    Type of identification produced: Include ID #

    Type of identification produced: Include ID #

Leave This Blank:


33. Print Only

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