PERMIT DOCUMENTS • Page 2 February 13, 2018
INSTALLATION AFFIDAVIT
WINDOW & DOOR (replacement)
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To: City of Boynton Beach, Florida
Department of Development - Building Division
Field Inspection Section
100 East Boynton Beach Blvd., PO Box 310
Boynton Beach, FL 33425-0310
Re: Permit No. 74 - 0660i/24 j 4LL0rJey
From: •
Scl5%vl pt' 19 Lei: _ i G,q //(Cont actor)
(7g36 ?rifle/dolt reAv (3OGu, p /,$ (Contractors Address)
Sake/7A t4w% (Owner/s Name)
7 ea m4 69P, Boiolin4 je,2iA-, It g,;1196. (Property Address)
CERTIFICATI N SELECTION: (Please check all that apply)
72/Certification of Window Buck and Door Buck Installation
❑ Certification of Mull Tube Installation
[' Other (glass block, etc)
I, j) ;i1 70/9 , am a licensed contractor
(license No. (Ge f SO4(ci, )and do hereby certify that all work(as indicated above)
has been performed and installed at the above address in accordance with the Florida Building
Code, Existing Building, as amended, and Manufacturer's Installation Instructions/NOA/Product
Appo als submitted.
Sfgn ture of Qualifier 144 (
Date •
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing inptrument was acknowledged before me this Cto, $. o9041 (date) by
Sv&t t v'd Laivi , who is personally known to me or who has produced
Cl... di_ (type of identification)as identifi• • • • r•
take an oath. •, .• � • mm =-91ss,e
Cmmri i Ti F�pires ri!p taN
Signature of person taking acknowledgement •►,b (( % � fa,: �� ��,,,
Name of officer taking acknowledgement—typed, printed or stampeu
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