Contractor'S Authorized Signature Form - State Of Florida County Of Palm Beach printable pdf download

CONTRACTOR’S AUTHORIZED SIGNATURE FORM

Qualifier ______________________

(Print name)

Company Name ____________________________________________

Certificate # ___________________ Expiration Date ______________

Mailing Address ____________________________________________

City ______________________ State _____ Zip Code _____________

Phone (

)

Fax # (

)

Cell # ( )_________

• Legible Copy of Agents Current, Drivers License or

Government Issued Photo I. D. Required with Form.

LIMITED POWER OF ATTORNEY FROM CONTRACTOR

Let it be known, that I, the above listed contractor, have made and appointed, and by the presents do make

and appoint as agent (print name): ________________________________________________________

to be true and lawful attorney for me and in my name, place and stead, for the sole, specific and limited purposes to

execute any and all documents, as restricted below pertaining to building permits issued and/or inspections

performed by Palm Beach County Building Department, as I the undersigned, might or could do if personally

present. The authority of the person appointed as my attorney and agent to exercise the powers granted herein

shall commence on the date set below and shall remain in full force and effect until the license expiration noted

above, or death or specific written recession by either party.

UNLIMITED

, Authorized Agent may sign for permits, document re-submittal routing form, submit

(U) If you select this category both Qualifier and Agent

& pick up revisions and/or documents.

must appear in person when filing this form.

RESTRICTED

, Authorized Agent restricted to, revise & pick up permits and/or documents, except

(R)

document re-submittal routing form.

I understand that by signing this instrument, I am authorizing Palm Beach County Building Department to process

permit documents and/or issue building permits based on the signature of my above-named attorney and agent. I

further understand that I am fully responsible and legally bound for all acts performed under my certificate number,

including those of the agent.

Signature ______________________________

Signature __________________________________

(Qualifier)

(Agent)

STATE OF FLORIDA

COUNTY OF PALM BEACH

Sworn to (or affirmed) and subscribed before me

Sworn to (or affirmed) and subscribed before me this

this _____day of ________________, 200_, by

_____day

________________,

200_,

____________________.

Personally

known

____________________.

Personally

known

_____or has produced identification

_____or

has

produced

identification

(#)_____________________________. Type of

(#)______________________________________

identification: ___________________________.

Type of identification: ________________________

________________________________________________

Notary Public- State of Florida (F.S.S.§ 117)

Rev. 07/08

(SEAL)

Contractor'S Authorized Signature Form - State Of Florida County Of Palm Beach

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