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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. ____________________________________________________________
   Qualifiers Company Name

   Qualifiers 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

    ___________________________________________________ Print, type or stamp name

29. Commission No: ______________________________

31. Identification

    1. Personally known

    1. Produced Identification

32. _________________________________
    Type of identification produced:

    Type of identification produced:

Leave This Blank:


33. Print Only

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