Fillable DESIGN PROFESSIONAL DIGITAL SIGNATURE AFFIDAVIT (City of Marco Island Florida)

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DESIGN PROFESSIONAL DIGITAL SIGNATURE AFFIDAVIT (City of Marco Island Florida)

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April 2016
Design Professional Name:
Company Name:
Design Professional License #:
Email Address & Phone:
Mailing Address:
Authorization. The Undersigned architect or engineer (“Undersigned”) understands that (s)he is authorizing the City
of Marco Island through its Building Services Division to accept his(her) digitally signed document.
Termination. If the Undersigned believes the security of the digital signature has been compromised, or simply
wishes to terminate the use of such signature, (s)he must file a written notice of termination with the Building Division.
Governing Law. The Undersigned understands that the electronic signing and sealing of documents is governed by
Florida law. Electronic submissions must meet state law requirements as described in the Florida Statutes Chapter
471.025, 481.221, and 668.001-006. Specifically, with reference to Florida Statutes Chapter 481 and Florida
Adminstrative Code Rule 61G1-16.005 for Architects, or Florida Statutes Chapter 471 and Florida Adminstrative Code
Rule 61G15-23.003 for Engineers.
Digital Signature Serial Number or Name of Certification Authority
By signing this document, you are not only agreeing to the foregoing but certifying that: Any willful falsification of any
information contained herein is grounds for disqualification.
Print Name of Design Professional Signature of Design Professional
State of Florida
County of
The foregoing instrument was acknowledged before me this day of , 20 ,
by , who is personally known to me or has
produced as identification.
Signature, Notary Public – State of Florida
(Seal)
Printed, Typed, or Stamped Name of Notary
This notarized document may be submitted via email to permitsubmittals@cityofmarcoisland.com
For more information about digital permitting visit:
www.cityofmarcoisland.com > Government > Building Services > Citizen Access Portal
Or send an email to permitsubmittals@cityofmarcoisland.com subject “more info”
DESIGN PROFESSIONAL
DIGITAL SIGNATURE AFFIDAVIT
FOR ENGINEERS, ARCHITECTS, LAND ARCHITECTS, SURVEYORS
City of Marco Island
Building Services Division
50 Bald Eagle Dr
Marco Island FL 34145
239-389-5059
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DESIGN PROFESSIONAL DIGITAL SIGNATURE AFFIDAVIT (City of Marco Island Florida)

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Completed 12 September 2021

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