PERMIT DOCUMENTS o`I�1" City of Boynton Beach J : J j
Building D •
ivision "0gui;nTc"4)Fr,_
CHANGE OF CONTRACTOR
CONTRACTOR
Know all men by these presents that I, Kenneth D.Taylor ,for The Rock Construction Co.of Fla., LL(
(qualifier) (company name- identical to license)
have been contracted by The Club at Boynton Beach, LLC to complete the The Club at Boynton Beach
(property owner's name) (describe work)
construction at 623 S. Federal Highway and agree to assume the responsibility for the work
(property location)
being done there, consistent with the plans and associated documents for Permit # 15-00003409 and certify that all
work will comply with the codes and ordinances of the City of Boynton Beach upon the completiorLof the project.
Kenneth D.Taylor
Qualifier's name (printed) Qualifier' si ature
STATE OF FLORIDA, COUNTY OF r
The foregoing instrument was acknowledged before me this [Vat oi,7 (date) by
'&cc e _ —1-0-4-eor , who is(rsonally know) to me or who has produced
(type of identification)as identification and who did(did not)take an oath.
•L)
Signature of person taking acknowledgment D dk. PUU t Stele of Floda
a ..:a V MThillk
Name of officer taking acknowledgment-typed, printed or stamped My commtaalm FF 174884
Title or rank Serial ••..
teens 11120/20
OWNER
Oliver VonTroll , do hereby certify that I am the owner/owner's agent of the above referenced
(property.owner/owners agent)
property (08-43-45-28-07-003-0050 )and do hereby hold harmless and release the City of Boynton
(property control number)
City of Boynton Beach of any and all liability arising from the transfer of the building permit(s)to the contractor mentioned
above. I certify that the above referenced contractor is my lawful agent empowered to complete the above referenced
construction work.
Oliver VonTroll
Owner's name (printed) Owner's signature
STATE OF FLORIDA, COUNTY OF 'QG\54-v, h—
The foregoing instrument was acknowledged before me this_ & ) (date) by
(:)\ V Ove—teak , who is ersonally known to me or who has produced
(type of identifica n a en l cation and who did (did not)take an oath.
(SEAL)
Signature of person taking acknowledgment ���)� '
Name of officer taking acknowledgment-typed, printed or stamped "e, Notary Pot SIaN c(Florida
td:tone V matte
Title or rank Se- rJad�rt7�
iasia EF se4
of Or Expires imam
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)7424350 Fax:(561)7424357
S:IDevelopment19uiIdingtForms&Templates1Change of Contractor (1/00,800,12492,111:13,3/03)