AUTHORIZED
AGENT
AFFIDAVIT
Charlotte County Building Construction Division
18400 Murdock Circle
Port Charlotte FL 33948
____________________________________________________________________________________________________________________________
_
I
_____________________
hereby
grant
authorization
to
(Contractor) (Authorized Agent)
to act in my behalf with the Charlotte County Building Division while conducting activities related
to
obtaining permits. These activities specifically include signing all documents requiring signature of
“contractor”.
is to be considered an agent of my business and
(Authorized Agent)
therefore the signature of said agent is binding and causes me to assume all responsibilities
connected to or associated with the signature as they may relate to my contracting business.
I ______________________, relieve the Charlotte County Building Division of,
(Contractor)
and agree to hold the Charlotte County Building Division harmless from, any and all responsibility,
claims or other actions arising from or related to the Division's acceptance of the above agent’s
signature for permit-related activities. I further understand that it is my sole responsibility to grant
and terminate any such authorization and to ensure that the Division receives timely notice of any
such grant or termination.
Signature of Contractor Signature of Agent
State Certification or Registration Number
County Certification Number (if applicable)
**PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED**
Notary for Contractor’s Signature: Notary for Agent’s Signature:
State
of
County
of
State
of
County
of
The
foregoing
was
acknowledged
before
me
this
day
of
,
,
by
The
foregoing
was
acknowledged
before
me
this
day
of
,
,
by
, who is personally known who is personally known to me, or
to me, or who produced as who produced as
identification. Identification.
Notary Public Signature Notary Public Signature
Print, Type, or Stamp Name of Notary Print, Type, or Stamp Name of Notary
**The Division, at its discretion, may require a contractor or license-holder to personally apply for or obtain a building permit
notwithstanding any authorization allowing another person to apply for or obtain any permit on behalf of a contractor, qualifier, or
license-holder.
