PERMIT DOCUMENTS L%( .
City of Boynton Beach
ttt
r � 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. 17000b;)--I
From: 'N 1-14rvlee5 1- I (Contractor)
/3/3 /V c w 4.5—bit ?(Ace tl4-,t L ?4 .41e R (Contractor's Address)
7r# zeleAke (Owner/s Name)
/R 9 SE ilmAue. —6,y101A. &NcIn 7:1z a3c (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
Certification of Door Installation
Other (glass block, etc)
I, Ton4 4fSakeL. , am a licensed contractor (license No.
SCc.t3tt51vSnt ) 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.
`
Silbil7
Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregDinncOnstni nt was acknowledged before me this y) 1 111 (date)by TO/L1 2-f S Li 'k'`s- ,who
is onall known to or who has produced (type of identification)as identification
and who did (did not)take an oath. _ _1sEa1 L
Signature of person taking acknowledgement A-b ; BARBARA BURKE
\`' Nohry public•State of Florida
Name of officer taking acknowledgement—typed, printed or stamped l Cammhebo arc 237326
Title or rank Serial numberYy Cm=
„�.,,r Wes Jun 4:2818
BatledtUmbl lineal lgnM1t •
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
S:IDevelopmenflBUILDINGIForms-Templates-Sfgnslwindow and Door Affidavit.doc(11/11)