The undersigned, _____________________ , as owner or officer of the owner of the real property located at
_______________________________________; Folio No. _____________________ (“Property”) hereby appoints and grants
authorization to ___________________________________________ (“Authorized Agent”) to act on behalf of the owner with
the City of Temple Terrace Community Development Department and other members of City staff while conducting activities
related to the development of the above Property, including, but not limited to filing applications and obtaining development
orders and permits. These activities specifically include signing all documents on behalf of the owner. Authorized Agent is to
be considered an agent of the owner’s business and therefore the signature of said agent is binding on the owner and causes the
owner to assume all responsibilities connected to or associated with the signature as they may relate to the Property.
The undersigned owner hereby relieves the City of Temple Terrace Community Development Department of, and agrees to hold
the City of Temple Terrace Community Development Department harmless from, any and all responsibility, claims or other
actions arising from or related to the Department’s acceptance of the Authorized Agent’s signature for permit/application and
other development related activities. The undersigned owner understand that it is his/her sole responsibility to grant and
terminate any such authorization and to ensure that the Department receives timely notice of any such grant or termination.
Owner's First and Last Name
Authorized Agent's First and Last Name
Owner's Company and Title
Authorized Agent's Company and Title
State of _________________ County of ___________________
State of __________________ County of ___________________
The foregoing was acknowledged before me this ___________ day of _____________________, _____________, by _________________________, who is personally known to me, or who produced ______________________________________________ as identification.
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