PERMIT DOCUMENTS . . i I (7 - 2C(4,
r�f 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. 1 10000e S-0(,)
From: Cv G QCxc-p-42 n'ra. _Lti
� (Contractor)
1 3 Ll l a 1 ---)q.."‘ OT k.) LA)6 FL 33 9) 1 (Contractor's Address)
0 ptlefii is SRuN G OS (Owner/s Name)
110 14,, FLO REN -r1 10 E (A) l (Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
iPertification of Window Installation
Certification of Door Installation
DOther
(glass block, etc)
I, �-COMM S t �av l S , am a licensed contractor (license No.
L S C n 2a -s 1 ) 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 7
Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this 7-/ (date)/-'/ 7 by
is personally known to me or who has produced eQ m�� Vint , won
(type of identification) as identification
and who did (did not)take an oath.
(SEAL)
Signature of person taking acknowledgement,
Name of officer taking acknowledgement- : :"`. A`:GEA YOUNG
typed, prince or sta d ; ° JAY CGMMEIGN.FF P51069
Title or rank 4
Serial number ::-C : EXPIRES:Ari'12.2020
sIFOI`RC &mawiYp Eu1]el Nark Sertms
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742.6350 Fax: (561)7426357
.S:IDevelopmentlBU1LDINGIForms-Templates-SignslWindow and Door Afdavit.doc(11/11)