City of Anna Maria BUILDING DEPARTMENT 10005 GULF: DRIVE ANNA MARIA, FL3 34216 TEL: 941-708-6132X25/F: 941-708-6136 Contractor/Agent Authorization Form LORIDA Date: do hereby authorize to act as my agent In securing permits in the City of Annal Maria for the period of through, lunderstand that! lam responsible fora any permits secured by my agent. Ifurther understand that each time my agent applies for ap permit, he/she must showi this authorization form to the permitting staff. THIS AUTHORIZATION WILL STAND FOR1 THE PERIOD GIVEN. ABOVE. Contractor's signature_ Name of Business phone # State registration / certification number Agent's signature State of phone # County of The foregoing instrument was acknowledged before me this day of 20__by (contractor's name). has produced asl dentification oath. Notary Public Signature:, Printed Name of Notary: My commission expires: who Is personally known to me or who and who did/did not take an Commission #