PERMIT DOCUMENTS •
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City of Boynton Beach
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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.,I h — 1. 65_
From: 2 �s�r nit? Cc ku �'Yn / �n� (CSotr rri,actor)
` cg Q 4 mC - s 41-9' 61ce /,Th41l FL 'tGOLntfaCtor s Address)
D--tGk ' J00 n 'n'Gere I I t f (Owner/s Name)
qty ao ?h OUE �yn)on Ohl (t SWW615eity Address)
CE IFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
ertificati of poor Installation
Other AklOn (glass block, etc)
I, „4 T C.' Col e , am a licensed contractor (license No.
(Z4nSo 1 7 ) 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 ufactur- 's Installation Instructions/NOA/ Product Approvals submitted.
15)4.n.tu a of •ualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH y� CO)he • -•. • . . ent was acknowledged before me thi/ /Cl )//7 (date) b `O , who
i- •ersonal . .• - o me or who has produced (type of identification) as identification
and who did (did not)take an oath. - drrJt.trrd/
( EAL)
Signature of personkg acknowledgem )'l
Name of officer taking acknowledgement--typed, printed or stamped - 6HpNNON n.LOCK Tho
notas,
Title or rank .••-w psetic•6Ws� -
Serial number ,sa-\ scomm, Notu f •t;9910 o2
tee}' „ .E.i Pie
4G'i:iSf
100 East Boynton Beach Blvd,PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)7424357
S:IDevelopmenttBUILDINGIForms-Templates-SignstWindow and Door Affidavit.doc(11/11)