April 2016
Name:
Company Name:
License #:
Email Address & Phone:
Mailing Address:
Authorization. The Undersigned Contractor understands that (s)he is authorizing the City of Marco Island through its
Building Services Division.
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
668.
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 License Holder Signature of License Holder
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”
DIGITAL SIGNATURE AFFIDAVIT
Contractor
City of Marco Island
Building Services Division
50 Bald Eagle Dr
Marco Island FL 34145
239-389-5059
click to sign
signature
click to edit
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