Statement of Fact and Informed Consent

Statement of Fact
And
Informed Consent

Permit #: _____________
Location: _____________

By my signature below I acknowledge that I have been informed of the following and have
given my informed consent to the terms and conditions hereof:

 

1.    I acknowledge that I must comply with all provisions of the above identified
       sign permit and the Lake Mary Code of Ordinances, including but not limited
       to, Chapter 155, Appendix I.
 
          2.    I agree that City officials, including but not limited to, Code Enforcement
                 Officers, Police Officers, Citation Officials, and Building Officials may enter
                 into or come onto my private property at the above identified location to
                 inspect all signage installed thereon to ensure compliance with the
                 Lake Mary Code of Ordinances and the above identified sign permit;
 
3.    I agree that a City official, employee, or agent may place an adhesive
       "Notice of Violation" on the face of the permitted sign if it is found to be in
        violation of the Lake Mary Code of Ordinances, or the terms of the above
        identified sign permit and I hereby indemnify, acquit, and absolve the
        City of Lake Mary, its officers, employees and agents of any liability arising
        from the placement of the Notice of Violation and covenant and agree not
        to sue the City of Lake Mary, its officers, employees or agents for any
        damages arising out of the entry on or into my property or the placement
        of the Notice of Violation.
 
4.     I acknowledge that I have signed this "Statement of Fact and Informed
        Consent” acknowledging my informed consent to the terms hereof, prior to
        issuance of the above identified sign permit, and further certify that I am
        the owner of the subject location, or that I am an authorized agent of the
        owner and have the authority to bind the owner to the terms of this
        “Statement of Fact and Informed Consent”.

The above permit is issued for a sign based on the following:

Zoning district: ______________________________
Type of use: _________________________________
Maximum Square footage and height allowed: _______________________
Amount permitted: _______________________
 

_____________________________________________
       Owner/Authorized Agent Signature
 
 
_____________________________________________
                     Printed Name
 
 
STATE OF FLORIDA
COUNTY OF SEMINOLE
 
Sworn to and subscribed before me this _________ day of _________________,
20______, by ___________________________, Applicant Authorized Representative,
who is personally known to me or who produced his/her Florida Drive’s License
as identification.
 
________________________________________
           Notary Public - Signature
 
 
________________________________________
         Notary Public, Printed Name
 
 
(SEAL)