PERMIT DOCUMENTS oAht�f = 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. '4 - 3F I •
1 �
From: (,UP((ilCll\St Ex\CA-r�S (Voter)
Mt-ZS CGY9 cA11- '1C y \t1 & FL 3nntractor's
Address)
3 gots.
(Owner/s Name)
3 i t me /b 2 (Property Address)
1301 kc^t gccwAt.. �L 331)24
CE ICATION SELECTION: (Please check all that apply)
Certification of Window Installation
Certification of Door Installation
nOther (glass block, etc)
I � � i c wen , am a licensed contractor (license No.
-0311509.74 ) 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.
��
2/74 .7
Si nature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH c� ` / ,./Q ,/��
The fore..'.• '• ..-i was acknowledged before me this G( �4 7 (date) by t V' JCS�/7f�who
• •ersonall known to me or who 'produced (type of identification) as identification
and who did (did not)take an oath. (S
Signature of person taking acknowledge ER Woe"ago
Name of officer taking acknowledge --typed, printed o tamped atter SION�FFgp2
Title or rank Serial n ber : ,�, .A My coa RESrwoascoriss-
duly 23 ° 9
•
'h.
.ni :199-0,5�
100 East Boynton Beach Blvd,PO Box 310, Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
S:IDevelopmentlBUILDINGIForms-Templates-Signslwndow and DoorARdavit.doc(11/11)