AUTHORIZATION FORM FOR EZ PERMITS
Expires 1 year from the date signed
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Please note: if Escrow is checked and sufficient funds are in the escrow account, fees will be automatically withdrawn from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.
THIS ORIGINAL MUST BE HAND DELIVERED OR MAILED TO OUR OFFICE. THIS FORM WILL BE KEPT ON FILE FOR 1 YEAR,
HOWEVER, IT CAN BE UPDATED AT ANY TIME DURING THE YEAR BY THE CONTRACTOR.
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
Commission No.
My Commission Expires:
1101 EAST FIRST STREET SANFORD FL 32771-1468 PHONE (407) 665-7050 FAX (407) 665-7486
bpcustomerservice@seminolecountyfl.gov
