PERMIT DOCUMENTS tCityIt
of Boynton Beach
'°N °` Building Division
LICENSED ROOFING CONTRACTOR
AFFIDAVIT
ROOF METAL & ROOF SHEATHING INSTALLATION
(EXISTING DETACHED 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, FL 33425-0310J- ..
Re: .Permit No. 17- 0► 1'"f- Sew-Aces
From: I cep I-nto'rct{ Qooctrea-+ 'Nc (Contractor)
24A S 2 SLJJ Willi anus- 4 3c)o (',cfie R say,.Ft 331ttontractors Address)
Mor- 'r RtS t S Le y (Owner/s Name)
15 9 5g 2/1411 C (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
QGertification of roof metal installation, flashing, underlayment.
OG` rtification of re-nailing roof sheathing, and removal and replacement of damaged or rotted wood.
Other 1i 0'T' NA Op 1 tJ p Q o L9& S
I, Vp p.J tc e Ca MMOCIC- , am certified as a roofing contractor (License No.
CCC 13290 it ) 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
re-rpol inspections. I have otified the owner of the property of this affidavit.
Li 9
G. tr L , Z�17
Signature ofQ ca- C �A� 1 Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH lel/ �^
The foregoing instrument was acknowledged before me this 1l l 1'2O17(date) by \IQI%1C •tinyie r , wh0
is personally known to me or who has produced ` (type of identification)as identification
• '
and who did (did not)take an oath. , ' 1 (SEAL)
Signature of person taking acknowledgement _?! re,
P1"111- v` 11 ty� tls, .-- .Wnoo0
Name of office taking acknowledgement-typed, printe. .r sta
Title or rank �� Q Serial number 3911 v 9 66Z8 6dd tt {NOIO}9nd.013 401141S c a
titi°3 MN
EVGENIYA PAVLYUKOV i ON
NOTARY PUBLIC, STATE OF FLOR ••
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach F r1/4. t'1k, r p � ( ��4�w arra 1 c9
I- .•-_ ,,,. 50 Fax:(561)7424357
S:IDevelopmentlauilding1FormsBTemplates1RoofingMetalBSheathinglnsta lationPolicyBARtlavit-182family(12/99,12/02,1/03,10/03,11/05,9496, 04/09,
7/12)