City of Temple Terrace Customer Service

2. Company Name *
4. License Holder *
6. Contractor License #*
8. I,*

   (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

10. First Name
11. Last Name
13. First Name
14. Last Name
16. First Name
17. Last Name
19. First Name
20. Last Name
22. First Name
23. Last Name
25. First Name
26. Last Name
28. First Name
29. Last Name
31. First Name
32. Last Name
34. First Name
35. Last Name
37. First Name
38. Last Name
40. 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.
42. I,*

    (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.

44. This authorization will supersede any previous authorization(s) and will remain in effect unless revoked by the undersigned in writing.
46. License Holder Signature:*
47. Date:*
    Date:
49. State of_________________ County of_______________
51. 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.
53. Signature of Notary Public*
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