PERMIT DOCUMENTS Alt 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. I 70000 2 86
From: M Iopivl4+P ICON, 5 GIi 1 Li/ - Art r (Contractor)
$_I 1WOOILL�4Y/ h 4- Eel- " 7vh RGy (Contractor's Address)
J AN e- S 1 Cir Iv` Q�p Rol., -4,4/FL 3342' (Owner/s Name)
14 13„c.d. .j0 d n r f acA (Property Address)
rG 33436
CE IFICATION SELECTION: (Please check all that apply)
ertification of Window Installation
Certification of Door Installation
nOther (glass block, etc)
20qese v1!2 e4 , am a licensed contractor (license No.
r_3c- 19Y-6c3 3 ) 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/NON Product Approvals submitted.
Signature ."Qualifier Date / �/
STATE OF FLORIDA, COUNTY OF PALM BEACH r�
The foregoing instrument was acknowledged before me Is a (date) by 17 / 17 , who
is personally known to me or who has produced (type of identifica on)as identification
and who did (did not)take an oath. (_SEAL)
Signature of person taking acknowledgement
ROSER7 T ROSS
Name of officer taking acknowledgement--typed, printed or stamped Notary Public-State of FIor10a
:::.4:17:1.; Commissi0n FF 958031
Title or rank Serial number nn1 comm.Ex ires
-' anaeo throo. p May 24,2020
Oh National Notary Assn.
100 East Boynton Beach Blvd, PO Box 310, Boynton Beach FL 33423-0310 • • - • -. : ) - • r : )742-0337
S:IDevelopment\BUILDINGIForrns-Templates-Signslwiindow and Door Affidavit.doc(11/11)