PERMIT DOCUMENTS L\TY On
tir City of Boynton Beach
TONG 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. 1700001957
From: SIW IMPACT (Contractor)
975 S CONGRESS AVE#102 (Contractor's Address)
MILLER RESIDENCE (Owner/s Name)
10 OAKS LANE (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
nCertification of Window Installation
nCertification of Door Installation
Other (glass block, etc)
ABDIEL LOPEZ , am a licensed contractor (license No.
CBC1251294 ) 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.
8/15/17
Si ature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing i" l s ent was acknowledged before me this 15TH (date) by AUG 2017 , who
personally known t or who has produced — .e of identification) as identification
and w o i did not take an oath. -
TCHARD
Signature of person taking acknowledgement �( ov„w�
CH'STISAPNf#FF226
.001111M
� MYCOMMISSION#FF226744
Name of officer taking acknowledgement–typed, printed or stamped v WIRES:MAY 04,2019
Bonded through 1st State Insurance
Title or rank Serial number
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)742.6357
S:I DevelopmentlBU!LDINGIFonns-Templates-Signs\Window and Door Affidavit doc(11/11)