PERMIT DOCUMENTS �,.,A / 7 - z 75
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City of Boynton Beach
`"r°M0 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,11FL 33425-0310
Re: !Peerrmit No. t -1 00 0 021 5(0
From: o\202 c4 RSiA rC II (Contractor)
1�1i l in c'crc�rvL.0\ c -. . � ci ,, 334tn2_(Contractor's Address)
-RP ilf A I. Cry (Owner/s Name)
553 SF 9 4 - ( 't C, lnyfl nn�en(Uf L33(LIqperty Address)
6CERTIFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
Certification of Door Installation.
QOther (glass block, etc)
I, 1ObQ 4f>OC�k , am a licensed contractor (license No.
f RA S I b 7_CR ) 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.
-.Ea- -,— ' ....—..../ 5'707
Signature of Q'alifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
-. ' .- I �
The for- l7 n��o /l
- acknowledged before me this (� f ` I I ( (date) by �T lihrtOdwho
is peer . o has produced (type of identification) as identification
I
'and who .i. .ld not)take an oath. \ I il/IVI YfY' (SEAL)
Signature of person taking acknowledgement IS I•
Name of officer taking acknowledgement-typed, printed or stamped_n J (1 1 e, / 1I eJ
Title or rank Serial number istabassas a.
1 . •• ASHLEY MONTES
( 3 Notary Public-Slale of Floilda
1[v eunmmmun a bb u[9139
1 %+ `' 'My Comm Expires Dec 27.2020
1 ?Ofr••••
9ontletl'Nov)Nalrnn,li NDlaiy Assn
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33425-0310 Phone: (561)742-0350 Fax: (561)742-6357
S:IDevelopmentlBUILDINGIForms-Templates-Signslwjndow and Door Affidavit.doc(11/11) .