PERMIT DOCUMENTS _ ze8
L f Y O
City of Boynton Beach
Building Division
I
!INSTALLATION AFFIDAVIT
I 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. ./!/0000 y(,/g
From: 'twit Delo r (Contractor)
( Contractor's Address)
14(#( US �[� ` ` ( Owner/s Name)
u sc. S P i� Gf0 W y ( Property Address)
CERTIFICATION SELECTION: (Please check all that apply)
Certification of Window Installation
❑Certification of Door Installation
Other (glass block, etc)
I, tUsUA9 , am a licensed contractor (license No. •
n
1. a. l J () i 0 1 and do hereby certify that all work (as indicated above) has been performed and
installed at the above ad.ress in accordance with the Florida Building Code, Existing Building, as amended,
and Manufacturer's Installation Instructions/NOA/ Product Approvals submitted.
Sign ture of Qualifier Date •
STATE OF FLORIDA, COUNTY OF PALM BEACH q e
The foregoing instrument was acknowledged before me this .L-02347 (.=e)by � SUS U.444/ ,who
is personally known to me or who has produced •--of identification)as identification
and who did (did not)take an oath. (SEAL)
Signature of person taking acknowledgement / tai BARBARA GURICO
Name of officer taking acknowledgement—typed, printed or stamped MY OMISSION IFF080008
• j * EXPIRES:APS 30.2018
Title or rank - Serial number Wee ilia
440•11..
tomoLrY6mlur
100 East Boynton Beach Blvd,PO Box 310,Boynton Beach FL.33425-0310 Phone: (561)742-6350 Fax: (561)742-6357
S:IDevelopmenttBUILDINGIForms-Templates-Signs1Window and Door Affidavil.doc(11/11)