State Licensing Board for
Residential and General Contractors
The Authorized Permit Agent form may be used by a licensed contractor to designate an individual to obtain permit(s) on his/her behalf for a project(s). The contractor should submit an Authorized Permit Agent Form for each project that he/she designates an individual to pull permits for. The form is to be given to the permit office in the city or county in which the project is located. Do not send a copy of this form to the Board office unless you are requested to do so.
237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440
www.sos.ga.gov
State Licensing Board for
Residential and General Contractors
Authorized Permit Agent Form
License verification by permitting office should be completed by visiting sos.ga.gov/plb/
Licensed Contractor: _____Individual_____Qualifying Agent
Name of licensed person ________________________________________________________
*Please attach a copy of Individual license or Company License (Reflects company and qualifying agent license number)
License number of individual or qualifying agent: ______________________________
Name of licensed company(if applicable)__________________________
License number of company(if applicable):________________________________________
I, ______________________________________________, hereby designate
Licensed Individual or Qualifying Agent
________________________________________________ to apply for and obtain the permit(s) for the
*Please attach a copy of the authorized permit agent’s driver’s license.
project at:
________________________________________________
Street address
________________________________________________
Apartment or Suite Number
________________________________________________
I, the undersigned, being the contractor as either an individual or a qualifying agent, do hereby affirm and swear, under oath, that all information on this form and on accompanying documents are true and correct.
Signature of individual or qualifying agent _________________________________________________
State of ______________________________ County of ____________________________________
Subscribed and sworn to before me this _______ day of ________________20__ |
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Signature of Notary Public______________________________ |
(Seal) |
237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440 |
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www.sos.ga.gov |
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