PERMIT DOCUMENTS •
or,i;
titCity of Boynton Beach
aBuilding 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 334''2//5-0310
Re: Permit No. 17 °°0 ° 0 T�3
From: UJAti'c-S hl1 NWot J ReQw t_ (Contractor)
a 2G CLI N I MoaPE R D - g o L PWreNit rt 33141(4Contractor's Address)
TIN/‘ kiA-f 42cnJ t-I (Owner/s Name)
t1 SU) 33R(1 (L . Igd`fnrvN ( eACN/RL 3 343CProperty Address)
CERTIFICATION SELECTION: (Please check all that apply)
1%46-edification of Window Installation
IjCertification of Door Installation .
Other ,�. ,L (glass block, etc)
l S-t s` Min )G , am a licensed contractor (license No.
U-(444,2 ) and do hereby certify that all work (as indicated above) has been performed and
installed at the above address in accordance with the 2007 Florida Building Code, Existing Building, as
amende•, and Manufacturer's Insta ation Instructions/NOA/ Product Approvals submitted.
•�' � [/J /fpdiPl/ 3 — 3 — ( 7
Signature of Qualifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this (date) by SCfr7ier., , who
tCpersonally known to me r who has produced (type of identification)as identification
and who did (did not)take an oath. ``\\����t\UWIIink;
Signature of person taking acknowledgement). tp , �.y a.
r GO ,
*/ une.ss/Dy Gv
Name of officer taking acknowledgement—typed, printed or stamped moo; '. m:r
Title or rank Serial number $p' ' • � vt
tz .bis 5:
PIS
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100 East Boynton Beach Blvd, PO Box 310,Boynton Beach FL 33425-0310 Phone: (561)742-6350 Fax: (561)742-6357
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