PERMIT DOCUMENTS 4 •
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411# City of Boynton Beach
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. I •
i
From: /4 !c-Ey elm 5cjaL./eLS, / C- , (Contractor)
E 4 7!y/ Re-2 /,45-ne.►c, 3 3 'f Z S (Contractor's Address)
l'C Ct &
Ft c (Owner/s Name)
6 Li Ck-s-CCA7ri DQ. fr Be 33y31 (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
❑Certification of Window Installation
F Certification of Door Installation
❑OthJ/err p (glass block, etc)
I, ULOC- 'JA' Ley , am a licensed contractor (license No.
( A'(_ 0c'72w/ )/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.
Jgllature of Qu fier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH 4,I
The foregoing instrument was acknowledged before me this/01103 date) by rICA -°
/ , 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 ��� q MATTHEW T REED
Name of officer taking acknowledgement-typed, printed or stamped ,., •- MY coMMissloN#0005499e
- EXPIRES December 13.2020
Title or rank • Serial number
100 East Boynton Beach Blvd,PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)742-6357
S:IDevelopmenflBUILDINGIForms-Templates-SIgnslWndow and Door AKdavit.doc(11/11)