HomeMy WebLinkAboutCEB AGENDA PKT 3-19-09MAR -17-2009 11 13 AM Coast Retail Systems Inc 321 574 1041
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CITY OF CAPE CANAVERAL,
AUTHORIZATION FORM
City of Cape Cavavcral Building Dcpartmmt 105 Polk Ave. Cape Canaveral, FL 32920
(321) 868-1222
(You may download this authorization: www,rnyfloridacom/cape, You may fax to: (321) 868-1247,
Date: Permit #:
CONTRACTORS AND SUBCONTRACTORS - PLEASE HAVE YOUR SIGNATURE
NOTARIZED AND SUBMIT THIS FORM WITH THE PERMIT APPLICATION,
I, hereby authorize
(Stat .i.pwise H—W—oar's :sma — PTCASE MitiT) �•
(Autiiorimd Fergon — PLEAS$ P#uN'r)
to obtain a permit on my behalf under my state license as issued by the Department of
Business and Professional Regulation, Construction Industry Licensing Board
(Spain License Number)
for the job site described below,
� Tyl?e ofPt'rmit
Building
PIumbing
Electrical
Mechanical
Roofing
Swimming Pool
Specialty Structure
L--
1 I IIC,f — 1pCGi7y •
Name of Property Owner
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l41r •r
Signature of License Holder
For Notary use only: State of Florida. County of Brevard
Sworn and subscribed before me this _j,�_ day of��_, 20, by
iarire of Appiicar�/
who Produced identification: or
is personally known to me.
Seal, `a,' Qawtmi•rP�rna633241
M� Canmfs�ion Eaoi<•A -b4 om
y„m a Rt _ c,,,,•y ►gnatule - Notary blic At Large
G:1Bldg.DeptFormslAuthorization Form ?his form may be duplicated.
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