Limited Power Of Attorney Form printable pdf download

Limited Power Of Attorney Form

B u i l d i n g D e p a r t m e n t

____________________________________________________________________________

Limited Power of Attorney

Date: _________________

I hereby appoint: ____________________________________________________________________

an agent of: ________________________________________________________________________

(Name of Company)

To be my lawful attorney-in-fact to act for me to apply for, receipt for, sign for and do all things necessary to this

appointment permit.

The specific permit and application for work located at:

____________________________________________________________________

(Street Address)

Expiration Date for This Limited Power of Attorney: ________________________________________

License Holder Name: _______________________________ State License Number: ___________________

Signature of License Holder: ___________________________________________________________

Witness Signature: ________________________________

Witness Signature:________________________________

Witness Printed Name: ____________________________

STATE OF FLORIDA

COUNTY OF VOLUSIA

The foregoing instrument was acknowledged before me this ____ day of _____________, 20___, by

__________________________________ who is ____ personally known to me or ____ who has produced

_________________________________________________ as identification and who did (did not) take an oath.

___________________________________

Signature

___________________________________

(Notary Seal)

Print or type name

Notary Public – State of Florida

Commission No. ________________________

My Commission Expires: _________________

___________________________________________________________________________________________________

City of DeBary Building Department

Tel. (386) 668-2040 Ext.320

Fax (386) 668-3508

Limited Power Of Attorney Form