PERMIT DOCUMENTS tr_ .�
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O = City of Boynton Beach
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nOP.et. Building Division
INSTALLATION AFFIDAVIT
WINDOW & DOOR (replacement)
•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. /4 aaoa3T3
From: leo ue tePoT (Contractor)
/ ° ( Contractor's Address)
I-' 0R/r- ( Owner/s Name)
- 3o4 KEW s v2 . di 310 ( Property Address)
KE TIFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
Certification of Door Installation
Other (glass block, etc)
I, = v (1t /U.Jf-L/ , am a licensed contractor (license No.
( (cj6.'i I`i L%7 0g2_,-) ) 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 Manufacturers Installation Instructions/NOA/ Product Approvals submitted.
•
r as. -
Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this (date)by ,who
is personally known to me or who has produced ,,,,J///// ' (type of identification)as identification
and who did (did not)take an oath. 'I (SEAL)
t,,
Signature of person taking acknowledgement L' „/ -,__i/.-/_4`
+P�." ,
Name of officer taking acknowledgement—typed, •rinted or stampe. BARBARA
GURICO
N$F
MY COMMISSION J FF 080008
Title or rank 'erial number * L,Ti` - EXPIRES:Ap130,2018
34.,..„F" Bar4rdlhry By tNery Win
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)742-6357
SiDevelopmennBUILDINGIForms-Templates-SignsiWindow and Door Affidavit.doc(11/11)