PERMIT DOCUMENTS •
o`t� City of Boynton Beach
Ott
Building Division
LICENSED ROOFING CONTRACTOR
AFFIDAVIT
ROOF METAL & ROOF SHEATHING INSTALLATION
(EXISTING ONE & TWO FAMILY DWELLINGS ONLY)
The City of Boynton Beach offers progressive inspections - call 742-6355
To: City of Boynton Beach, Florida
Department of Development - Building Division
Field Inspection Section
100 East Boynton Beach Blvd., PO Box 310 •
Boynton Beach,/ U FL33425-0310
Re: Permit No. Ji - 74/472
From: 3R0/5 Poorsn)a CD /.,dr (Contractor) •
310 d' ,4V Nuel �rz,y to ' fl33y16-95toiContractor's Address)
SAlethr.S e e-I se' (Owner/s Name)
2.0A 3 S c ) ) 4 penae (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
Certification of roof metal installation, flashing, underlayment.
.�
ICertification of re-nailing roof sheathing, and removal and replacement of damaged or rotted wood.
XlOther -;/{ in • 10(05tcss
Lir-o
I, r{ 1&649 0 •J am certified as a roofing contractor (License No.
CCC O SSU"7 ) and do hereby certify that all roof work (as indicated above) has been performed
at the above address in accordance with Chapter 15 of the Florida Building Code, Existing Building, as
amended, and Manufacturer's Specifications. I understand that the City of Boynton Beach offers progressive
rt,r•
• •••::" •"S,_' ve notified the owner of the property of this affidavit. /s /C
Sig - .— of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH /
The foregoing instrument was acknowledged before me this 47'OS'a70//i (date) by AAa2y 1//��(A-1no4 , w• ham.
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
Name of officer taking acknowledgement--typed, printed or stamped
Title or rank Serial number 47:::1.7% CLAUDIA NELSON
3 * CONAlISSJ0N 0 FF 151238
EXPIRES:Seplember23,2018
'hor Bended Tent Budget Notary Senior
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)742-6357
SADevolopmenPBBuilding\Forms&Templates'RoofingMetal&SheathinglnstallationPolicy&AHidavir-182ramily(12/99,12/02,1/03,10/03,11/05,9/06,04/09)