PERMIT DOCUMENTS oA •
`0, 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 I
Boynton Beach, FFL'33425-031/c7fl
0
Re: Perm,it N . J� b�D C/
From: °SS u& h-4' / (Contractor)
7rf, PSCrr/t !/f-'
'/ ^-f L4> 17 3?fr(r7 (Contractor's Address)
S'! , L, (�, -I /AeS //c (Owner/s Name)
3/y Sc- ILP/ Am (Property Address)
I
CERTIFICATION SELECTION: (Please check all that apply) I
•certification of Window Installation I
certification of Door Installation
Fl Other (glass block, etc) I
I, �lv`'te I /floc , am a licensed contractor (license No.
c a "J76/7 9 ) and do hereby certify that all work (as indicated above) has been performed and
installed at the abov address in accordance with the Florida Building Code, Existing Building, as amended,
and Manufactu•- s Installation In ction NON Product Approvals submitted.
Signatu • of Qualifier Date
STATE OF . - - e . 7i F PALM BEACH /
The foregoin• '• ment - acknowledged before me this / J date)by .2;414f(11(DCr ,who
ise to e or who has produced (type of identification)as identification
an. w o did(did not)take an oath. (SEAL)
'Signature of person taking acknowledgement ,11,0 PETER NUNEZ
acknowledgement-typed, print=• or sr. ped UBLIC
°e*"<n, roa STATE ONOTARY FF FLORIDA
Name of officer takingacknowled ement- M
Title or rank Serial number yet!? Cammp FF189093
CE 191 Expires 1/12/2019
100 East Boynton Beach Blvd, PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax:(561)742-6357
S:IDevelopmentBBUlLDINGIFonns-Templates-Signstwindow and Door Alfidavit.doc(11/11)