PERMIT DOCUMENTS „I.,‘,.”.
o`t� = City of Boynton Beach
on '' 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. I 1 — 7...7-C1-
•
From: L o�e CS (Contractor)
l 5-0 0 Cc(pu(a tr. Q nkn Seal FL/ ;2)9 2((Contractor's Address)
S Co-l" Or )' (Owner/s Name)
)09n Nlv gra Sf. Pjuyn4-en teat), 1L, 3-312C (Property Address)
CEf3.TIFICATION SELECTION: (Please check all that apply)
C ification of Window Installation
Certification of Door Installation
Other ^, (glass block, etc)
n
I, A-er �lac , am a licensed contractor (license No.
C•C7C1t^OV- ) 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' - allation Instructions/NOA/ Product Approvals submitted.
V10117—
Signature of Qualifi: Date
STATE OF FLORID• OUNTY OF PALM BEACH � //��
The foregoing instrument was acknowledged before me this ti Jo ill. (date)by ((�� F��t( Crictip , who
ispepe o lly known toomor who has produced (type of .•• ' -. . )as identification
and who did (did not)take an oath. (SEAL)
Signature of person taking acknowledgement ..
Name of officer taking acknowledgement—typ-., p.nted or stamped / SVON REMY
t MY COMMISSION#FF126064
Title or rank S: ial number I ' EXPIRES:MAY 26,2018
`a' Bonded through 1st State Insurance
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
S:IDevelopmernIBUILDINGIForms-Templates-Signs1Window and Door Affidavit doc(11/11)