PERMIT DOCUMENTS L•i+n
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 X33425-0310 •
Re: Permit No. I l' 3(il,
From: LUA2T'r hu/NDOW / A 2 (Contractor)
jj t 6 Cc l r.,T lt4001a - D . Bcca P/41210 L (Contractor's Address)
(AJ/LL/Priv( M PT7?/'YV p (Owner/s Name)
2 0(P) S revan. t q ,43a a Po y,�1V 06)4c4Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
[rtification of Window Installation
nCertification of Door Installation -
nOther (glass block, etc)
I, irrederA.4 V- M Per?-tea/G , am a licensed contractor (license No.
U-/5'91x3 ) and do hereby certify that all work (as indicated above) has been performed and
installed at the above address in accordance with the 2007 Florida Building Code, Existing Building, as
amended, nd Manufacturers Installation Instructions/NOA/ Product Approvals submitted.
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1 s
'` Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this (date) by , who
Cursonally known to meyr who has produced (type of identification) asidentification
and who did (did not) take an oath. ��� IRIA11/�4�i
Signature of person taking acknowledgement X4.4, c,,."-p a. • G� ;S :• conMlA
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Name of officer taking acknowledgement--typed, printed or stamped S_:• June y'O G%
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Title or rank Serial number '121 • -it 541 E.
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tr -1�IglIDlni iOP\\\\\i
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
S:IDevelopmentlaUILDINGIFonns-Templates-SignslWindow and DoorAffidavit.doc(11/11)