PERMIT DOCUMENTS �' City of Boynton Beach
" " 047 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. / 6 d000 0 7o I
From: /ka. 9e,t Ce9A9Ki ✓ r� /��/� (Contractor)
,,gq 1 w �bo l bl�rr� ALL fCc(- (Contractor's Address)
C4 RA- t j1IMi ) (Owner/s Name)
2. 3 S £( S w (,( -1- in (Property
,�I ,/v-Q-- (Property Address)
R/ ri 3 1c
CERTIF ATION SELECTIO�/(PlearN se3
check all that t apply)
C ification of Window Installation
Certification of Door Installation
Other (glass block, etc)
r2✓L $0c-2-e-4 , am a licensed contractor (license No.
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 Approvals submitted.
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11
/ 6
Signa ure .f Q ifier Dae
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 (type of identification)as identification
and who did (did not) take an oath. (SEAL)
Signature of person taking acknowledgement
"'1' ROBERT T ROSS
Name of officer taking acknowledgement--typed, printed or stamped �. fiery Ihtblic•State offload.
t „ • Corm futon•FF 958031
Title or rank
Serial number .�_?. • My Comm.Expires May 24,2020
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100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Pho-e: (561)742 •350 . F. • . . 2-6357
S:IDevelopmentlBUILDINGIForms-Templates-Signs\Window and Door Affidavit.doc(11/11)