PERMIT DOCUMENTS I,,IW&.bopi4vn-bene t,or�r
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' = City of Boynton Beach
.�Ur1� • 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. 1 / �7 G OT q1 Q�/
From: 51-. vec S7c-er ('6Wnterac ) (Contractor)
-)-S- SE (" Ge- 0-9 A- f aa9af Contractor's Address)
STeve S((cef (Owner/s Name)
'ZXCC r- ('ce 1 .Igr1JIv VCN,PC(Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
nCertification of Door Installation
Other (glass block, etc)
I, Ci-€v€ S(!LW , am a licensed contractor (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.
Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH a-eV
e- c(r
The foregoin instrument was acknowledged before me this 1(1-1 I i (date)by ho
is ersonatfy known tom or who has produced (type of identification)as identification
andwho I id not)take an oath. ,,, (SEA IKA ROCKET! 1
�J �` Zt- 9 'PL Notary Public �State of Florida
Signature of person taking acknowledgement yyg,{)v� 1�1o�fy� ) t
Commission A GG 017858
Name of officer taking acknowledgement-typeddf,,p� rinted or stamped t V-A .d+ My Comm.Expires Sep 19.2020 ,
Title or rank 5ene1 numberD 'i ( I,'. BondedmraupbrlabonalNotay Assn.
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax:(561)742-6357
S:IDevelopmenitBUlLDINGIForms-Templates-Signslwindow and Door ARdavil.doc(11/11)
City of Boynton Beach
Building Division
TON e
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/NOA/
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 calling the inspection clerk 24 hrs in advance at (561)
4 • 142-61551,T.:
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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
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CITY OF BOYNTON BEACH
riiP� DEVELOPMENT DEPARTMENT I BUILDING DIVISION
tr 100 East Boynton Beach Boulevard•Boynton Beach,FL 33435•(561)742-6350•Fas 742-6357
~roN 9
APPLICATION FOR: ❑ EXTENSION V,Ic*REINSTATEMENT
SELECT ONE: ❑ Permit ❑ Permit Application (max of(3) three extensions)
Project Name:
Permit # I/ 0 0 a 0 / 9 9 ' Job Address: 610' 56 37 OI,2CLE C 7ccju ki4p,r'�,33.-13-
Contractor of Record: 57t(/ Rile(
Phone:5-(0g93) Email: apt le upig e Sp,t/e ('Om
Mailing Addressers- SE, /6v Cjetu 9A
Citybvj ,pA) cd- State: FL__ Zip Code:219d
Detailed reason for the extension: QAN our OAC' MPP/P t f rG 41S1' , -f1.1#BA .
so yr -o k nyiE
I, the undersigned, am requesting an extension/reinstatement for the item indicated above. I understand that
submittal of this form does not constitute in itself approval of the extension/reinstatement. �
Qualifier/Authorized Agent a /7'r /Sar/ture Date
S7g/5J 5,kEs
Printed Name
FOR OFFICIAL USE ONLY t�,, /I
Date of Explration:1 Processing Technician Initials IVB
Application Extension(max of(3)three extensions): 0l"$50.00 ❑2ntl$75.00 03'd$100.00
Permit Extension: 01"$50.00 02nd$75.00 03rd$100.00 ElExtension beyond 90 days$250.00(Requires
Building Board of Adjustment&Appeals Approval)
Permit Reinstatement Fee: Total Permit Value: zkoo ---
Under 180 days of inactive status O.......... it Times 2.3%
Permit Fee: j/� 2
Over 180 days of inactive status ❑..........$ or
Over 180 days of inactive status ...' 1% Times 30%
(Whichever is greater) Reinstatement Fee:
g! Approved,extended f• • • Denied **Additional Impact Fees may apply
"Revie e• • sing Official Date
S:\Development\BUILDING\ • s-Templates-Signs\Application for Extension-REVISED 1-20-2016.docx