PERMIT DOCUMENTS C rte _ 'ft (tof€ko- nton Beach = .. .:
',Jong'° Building •Division
INSTALLATION AFFIDAVIT
WINDOW & DOOR (replacement)
To: City of Boynton Beach, Florida
Department of Development - Building Division
FieldInspection'So tion
100'EastBoyntorr Beach Blvd., PO Boit 310
Boynton Beach, FL 33,3425-0310 Q
Re: Permit No. t--9-4-9-r /// /61 `487- '
2L�� .
From: d " /nn ce Peruice& ...b7 C (Contractor)
.26 0 0 Ce uc„•ti, 64.Q_ 77-04 (Contractor's Address)
. MI k Phil a (QwneNs:Na7ne)„
/1 /0 3 u /3 Rut 1 /36 ,339a6 (PropertjiAddress)
•'
CERTIFICATION SELECTION: (Please check all that apply)
%giCertlficationof Window Installation
QCertifIcation.of Door Installation )
QOther —Orr* 62:iie// gn
I (glass block, etc) •
I, '' A a4 Ai.t, , am a licsed. contractor, (license No.
C (re 00 7a Sit and do reby certify that all work (as Indicated above) has.been Rerfacmed and
installed at the above address In accordance with the 2007 Florida Building Code, Existing Building, as
amended, and Manufacturer's Installati�n Instructions/110A/Product Approvals submitted.
/ i • �gas/ J
Ighature of Qualifier Date _ L
STATE OF FLORID• , COUNTY OF PALM BEACH
3/2 81ic �7 �{ nn
The foregoing Instrument was acknowledged before me this (date) by JPO // @Yt , who
Is-personall known to:me or who-has produced (type of Identification)as Id tification
nd who did(did not)to ath. . '(SEAL)
Signature ofperson takingacknowledgement �1X 7 �` •�"`F MATTHEW!.
9 9 /��/' NY C011l,145910N1EE653B27
*
Name of officer taking acknowledgement—typed, printed or stamped . EXPIRES:oecemberl,2016
%hi ie Blow ,daskarf Swim
Title or rank Serial number
II
rI
100 East Boynton Beach Blvd, PO Box 310 Boynton Beach FL 33425-0310 Phone: (561) 742-6350 Fax: (561)742.6357
S:IDevelopmentMBUILDINGIForms-Templates-sIgnswWlndow end Door AfldavItdoc(11/11)