1101 EAST FIRST STREET SANFORD FL 32771-1468 PHONE (407) 665-7050 FAX (407) 665-7486
bpcustomerservice@semiolecountyfl.gov
AUTHORIZATION FORM FOR EZ PERMITS
Expires 1 year from the date listed
Payment will be via __Credit Card __ Escrow
Please note: if Escrow is checked and sufficient funds are in the escrow account, fees will be automatically withdrawn from
your Escrow Account for applications submitted through the EZ Permit process.
Date:
I hereby name and appoint the below listed individual(s) as an agent of:
(Name of Company)
to be my lawful attorney-in-fact to act for me to apply for, receipt for, sign for and do all things necessary to obtain permits
via the EZ Permit program:
Name: ______________________________________ Email: ____________________________________________
Name: ______________________________________ Email: ____________________________________________
Name: ______________________________________ Email: ____________________________________________
Name: ______________________________________ Email: ____________________________________________
License Holder Name:
State License Number:
License Holder Email: __________________________________________________________________
Signature of License Holder:
STATE OF FLORIDA )
COUNTY OF )
The foregoing instrument was acknowledged before me by means of [ ] physical presence or [ ] online notarization, this
_____ day of _________________, 20___, by _____________________________ (name of person acknowledging),
who is [ ] personally known to me; or [ ] has produced __________________________ as identification.
Signature of Notary Print or type Notary name
Notary Public - State of
Commission No.
(Notary Seal) My Commission Expires:
