City of Temple Terrace Customer Service

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Contractor Authorized Agent Affidavit

  1. (License Holder) hereby grant authorization to the following persons to act as my agent with the City of Temple Terrace while conducting activities related to obtaining permits and/or inspections

  2. The Authorized Agent(s) is to be considered an agent of my business and therefore the signature of said agent is binding and causes me to assume all responsibilities connected to or associated with the signature as they may relate to my property.
  3. (License Holder) relieve the City of Temple Terrace and the employees and elected officials of, and agree to hold them harmless from, any and all responsibility, claims or other actions arising from or related to the Department’s acceptance of the above agent’s signature for permit related activities. I further understand that it is my sole responsibility to grant and terminate any such authorization and to ensure that the Department receives timely notice of any such grant or termination.

  4. This authorization will supersede any previous authorization(s) and will remain in effect unless revoked by the undersigned in writing.
  5. State of_________________ County of_______________
  6. The foregoing instrument was sworn to (or affirmed), subscribed, and acknowledged before me by means of ☐ physical presence or ☐ online notarization, this ____ day of __________, 20__ , by ___________________ (name of person making statement), who is personally known to me or has produced ___________________(type of identification) as identification.
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