PERMIT DOCUMENTS le
City of Boynton Beach
Building Division
INSTALLATION AFFIDAVIT
WINDOW & DOOR (replace_ men+�
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.
From:
tea ,
L (Contractor)
P_ - 1C ) - (Contractor's Address)
As
Ka) _ (Owner/s Name)
(Property Address)
aCERTIFICATION SELECTION: (Please check all that apply)
, ertification of Window Installation
LJCertification of Door Installation
Other
SQ.V11 (glass block, etc)
" i
, am a licensed
license No.
- = 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.
4
izgnature of Qualifier
STATE OF FLORIDA, COUNTY OF PALM BEACH Date
The foregoing instrument was acknowledged before me this J2-� I(
is personally known to who has produced ja291�—(date) by Za������i who
(type of identification) as identification
and who did (did not)take an oath.
Signature of person taking acknowledgement I (SEAL)
air
Name of officer taking acknowledgement—
typed, pri. ed or tamped ANGELAYOUNG
Title or rank a 6 Y COMMISSION;FF 951E69
Serial number a : ' EXPIRES:Aorrl 12.2020
3oNe1 i'[.2uGpxI Naar}&Aloes
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)7424350 Fax: (561)742-0357
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