PERMIT DOCUMENTS C •
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Alt City of Boynton Beach
4,0. 0Building 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. /700 /6,Li
From: Mark Collins, Window World of West Palm Beach (Contractor)
1500 North Florida Mango Road, Suite 16B, West Palm Beach, FL 33409 (Contractor's Address)
Ryan Scott (Owner/s Name)
3 West Chesterfield Drive (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
•Certification of Window Installation
nCertification of Door Installation
❑Other (glass block, etc)
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s , am a licensed contractor (license No.
cac1260052 A and do hereby certify that all work (as indicated above) has been performed and
installed at I. - abov dres in . ordance with the Florida Building Code, Existing Building, as amended,
and Man.6 acturer tall. '. .ns/NOA/ Product Approvals submitted.
( OP 7
mature of Qualifier Dat
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this oa/ro/20/7 (date) by Mark Collins who
is personally known to me or who has produced -personally known to me- (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 d ;� a;; PAULA J. LEBLANC
Title or rank f= .R= Notary Public. State of Florida
Serial number -e ;Ej My comm. expires Nov. A.2019
"',?,;;°o`c. Commission Number FF933886
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100 East Boynton Beach Blvd, PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
SADevelopmenttBUILDINGIForms-Templates-SignslWindow and Door Affidavit dac(11/11) 'I
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