Authorized Permit Agent Form – Fill Out and Use This PDF

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 ____________________________________