Building & Permitting 49 0 3 R D S T N W 86 3 -2 91 - 56 95 M - F 8A M - 5 PM DULY AUTHORIZED REPRESENTATIVE EMPLOYMENT AFFIDAVIT This affidavit is required pursuant to the City of Winter Haven Alternative Plan Review and Inspection Registration Program. §553.791(16), Fla. Stat. (2021). I, ______________________________________, the Private Provider do hereby affirm that the Duly Authorized Representative listed below, is my employee and is entitled to receive reemployment assistance benefits under Chapter 443 of the Florida Statutes, as required by Section 553.791(8) of the Florida Statutes. DULY AUTHORIZED REPRESENTATIVES: (List individually; use a separate form for each Authorized Representative) Print Name License Number – Standard Plans Examiner__________ Standard Inspector___________ Trade Categories_____________________________________________________________ Submit resumes of each Duly Authorized Representative and copies of their licenses Signature of Private Provider________________________ License # PRIVATE PROVIDER FIRM THIS SECTION TO BE COMPLETED BY A NOTARY PUBLIC: STATE OF _______________ COUNTY OF ________________ The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization this _____ day of ____________, 20____, by_________________________, who is ☐ personally known to me or ☐ has produced _________________________________ as identification and who (did) (did not) take an oath. _________________________________ SIGNATURE OF NOTARY PUBLIC M Y WIN T ER H A V EN. C OM PAGE 1 OF 1