PERMIT DOCUMENTS soft
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City of Boynton Beach t%
4,„.a` Building Division CoA `'',. %..z4,„
Ra, crF, - c'5, ��
CHANGE OF CONTRACTOR ''y-014 -
otpCONTRACTOR
Know all men by these presents that I, Kenneth D.Taylor , for The Rock Construction Co.of Fla.,LL(
(qualifier) (company name– identical to license)
have been contracted by The Club at Boynton Beach, LLC to complete the The Club at Boynton Beach
(property owners name) (describe work)
construction at 623 S. Federal Highway and agree to assume the responsibility for the work
(property location)
being done)there, consistent with the plans and associated documents for Permit # 15-00004634 and certify that all
work will comply with the codes and ordinances of the City of Boynton Beach upon the completion of the project.
Kenneth D.Taylor
Qualifier's name (printed) Qualifier si nature
STATE OF1 FLORIDA, COUNTY OF ePeLVON,Tope oiL
The foregoing instrument was acknowledged before me (date) by
\\ vP
P-(x -e� L TO 1 }n r' , who is ersonalhnow to me or who has produced
(type of identification)as identification and who did (did not)take an oath.
� (� (SEAL)
Signature of person taking acknowledgment \(Qom t
Name of officer taking acknowledgment-typed, printed or stamped "�h Hoary Public WhiStatele of Florida
i dere Wh+�Yo
Title or rank Serial or is Commission FF 174684
•
OWNER
Oliver Vt nTroll , do hereby certify that I am the owner/owner's agent of the above referenced
(property owner/owner's agent)
property(08-43-45-28-07-003-0050 ) and do hereby hold harmless and release the City of Boynton
I (property control number)
City of Boynton Beach of any and all liability arising from the transfer of the building permit(s)to the contractor mentioned
above. I certify that the above referenced contractor is my lawful agent empowered to complete the above referenced
construction work.
Oliver VonTroll �� _'�s—���
Owner's name (printed) Owner's signature
STATE OF FLORIDA, COUNTY OF PCT \ \✓ecspL
The foregoing instrument was acknowledged before me hie (date) by
L5.L.J'Q,r U isr.-CCT5.1 , who is ersonally known to me or who has produced
(type of identifica ldentl kation and who did (did not)take an oath.
(SEAL)
. Signature of person taking acknowledgment \y �Q�_ ' nibs _
Name of officer taking acknowledgment-typed, printed or stamped
.. 1 Er Warm°_ali.6,ete of nom.
Title or ranI
k ...ell b dfrgnm�iI-P
Nay Embrea 11Rar201a
100 EastiBoynton Beach Blvd,PO Box 310, Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax:(561)742-6357
evelopme
S:1Dnfleuilding1Fomis&TemplateslChange of Contractor (1/00,8/00,12/02,1/03,3493)