PERMIT DOCUMENTS G..Y On
o`�O� City of Boynton Beach
"rot, .` 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 33425-0310!
Re: Permit No. f 1- ?111(1
From: Rttg( 1 « (Contractor)
1046 SW 1)!" st 8x4 kir, ' - -g3 (Contractor's Address)
-Torn 11ev� , (Owner/s Name)
700 4xuoiNs Wt6* tl 6,ymiar` Q,rack P, (Property Address)
33-13?
CERTIFICATION SELECTION: (Please check all that apply)
❑X Certification of Window Installation
❑Certification of Door Installation
Other (glass block, etc)
Rant( Litt' , am a licensed contractor (license No.
t_)-•h'7nlo ) 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.
1 3/afw17/
Signatu ladalifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this (date)bangiliteg,who
is personally known to me or who has produced S (type of identification)as identification
and who di did no ake an oath. I r _rte (SEAL)
Signature of person taking acknowledgement ,_ , •
� II
Name of officer taking acknowledgement-typed, printer . stamped + - - - - - - -
Title or rank Serial number }s1Z" ELIZABETH A
! , Notary Public•Mats ot•Florida
•
t • j• •- Commission I FF 976696
ted, My Comm Expos Apr 5.2020
Abtt anKut m..NtlMNNedryMr
4 _ _
100 East Boynton Beach Blvd, PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax:(561)742-6357
S:IDevelopmenttBUILDINGIForms-Templates-Signs1Window and Door Affidavit.doe(11/11)
City of Boynton Beach
rf�P= Building Division
7.0N
WINDOW & DOOR INSTALLATION CERTIFICATION
FOR LICENSED CONTRACTORS ONLY
I. PURPOSE
The purpose of this Policy is to provide a method for certifying installation of replacement
doors and windows. This policy applies only to licensed contractors or owner qualified
for exemption under Florida Statute 489.103 (7)
II. AUTHORIZATION
Section 104.12 of the Boynton Beach Amendments to the Florida Building Code as
adopted by the City of Boynton Beach, provides that requirements necessary for the public
safety, health and general welfare not specifically covered by the standard or the Building
Official shall determine other technical codes or policies.
III. APPLICATION
Qualified applicants may certify the window and/or door installation by preparing an affidavit
certifying that the installation of the window and/or door complies with all codes, ordinances,
rules and regulations; that the qualifier or designee personally inspected the specific job; and
that the window and/or door was installed according to the 2010 Florida Building Code, and
Existing Building Code, as amended, and the Manufacturer's Installation Instructions/NON
Product Approvals.
This affidavit must be presented to the inspector at the Final scheduled inspection on-site.
The Structural Building Inspector will fail the inspection until certified by the applicant or pass
the inspection if the signed affidavit is present at the job site. A Final is the only scheduled
inspection and an.affidavit supplied, the Inspector shall add the comment, "CERTIFIED," and
pass the inspection. ,
Inspections may be requested by balling the inspection clerk 24 hrs in advance at (561)
742-6355.
AROM x136/.103
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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