PERMIT DOCUMENTS 4•T
ins
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 33425-0310
Re: Permit No. 14-3553
From: FLORIDA HOME IMPROVEMENT ASSOC (Contractor)
3044 SW 42 STREET HOLLYWOOD, FL 33312 (Contractor's Address)
HAVE (Owner/s Name)
234 SW 11TH AVENUE (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
❑■Certification of Window Installation
❑■Certification of Door Installation
❑Other (glass block, etc)
WAYNE THOMAS BURNETT , am a licensed contractor (license No.
CGC061990 ) 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.
02/20/2017
Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this 02/20/17 (date) by WAYNE BURNETT , who
isteLsonally known o me or who has produced (type of identification) as identification
and who did (did not)take an oath. S
Signature ofperson takingacknowledgement .•
g -- v��`c JOSEPH JABBOUN
Name of officer taking acknowledgement—typed, inted or stamped ' \ Notary Public•State a1 F851da
Title or rank Serial number = Cemmhel0n r FF 171851
%:,),-1,11M Comm.Expires Oct 27,2018
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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
S:IDevelopmentlBUILDINGIForms-Templates-Signs\wmdow and Door Affidavit doc(11/11)