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527 ATLANTIC BEACH CT PLRS19-0043 PLBG PERMIT PlumbingPermit Application **ALL INFORMATION �g�'. iHIGHLIGHTED IN 44' ,4t City of Atlantic Beach Building Department GRAY IS REQUIRED. v— 800 Seminole Rd, Atlantic Beach, FL 32233 ,)y. Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: PL Q.S1c(- ©O(-(3 JOB ADDRESS: 5n k-tlq vttl c Rem Cf PROJECT VALUE$ COS OO ANEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY Bathtub 3 Septic Tank& Pit Clothes Washer i Shower 3 Dishwasher r Shower Pan 2- Drinking Fountain _ Slop Sink Floor Drain -- Three Compartment Sink Floor Sink — Toilet 5 Hose Bibs 3 Urinal Kitchen Sink i Vacuum Breakers –" Laundry Tray I Water Connected Appliances f Lavatory . Water Heater I Other Fixtures Water Treating System __L___ ❑MISCELLANEOUS ❑Sewer Replacement ❑Back Flow Preventer ❑Lawn Sprinkler System (number of sprinkler heads) ❑Grease Interceptor (Trap) gallons (Requires 3 sets of plans) El Well **SJRWD Well Completion Form.Completed form to be submitted to the Building Department for final inspection. ** DOther Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Owner Name: 01 Chael & i-01ly ( ClV? Phone Number: Plumbin Company: gA 6-1 plUynbth91(0. Office Phone: 'O f•- 273-3585 Fax&jot-3.23-3 D l t Co. Address: 2232 COV NY kt-e. Sc1,Vial'e Bist4 City: TAGlcsvhvi(l a State: 1 L Zip: 3�211D License Holder: (7e h e c - ko v eR State Certification/Registration # G p C 0225'3 Notarized Signature of License Holder 0 ' % N-1 The foregoing instrument was acknowledged before me this Jo- day of All-elf , 20 ]11 , in the State of Florida, County of p1^VaI LORI S.NORDGREN /I / /iL ___ ry PuDtk-State of FlorWt Signature of Notary Pu is ;1 ,/ . I Personally Known OR [ ] ProducedIdentificaon°through National Notary Assn. Type of Identification: Ip Updated 10/17/18 km@ band C p ( oftpviotn , con 'sr�` t,, Cash Register Receipt Receipt Number City of Atlantic Beach R8276 'r Jj DESCRIPTION ACCOUNT QTY PAID PermitTRAK "$271.63 PLRS19-0043 Address: 527 ATLANTIC BEACH CT APN: 169505 1415 $271.63 PLUMBING $265.00 PLUMBING BASE FEE 455-0000-322-1000 0 $55.00 PLUMBING FIXTURES 455-0000-322-1000 30 $210.00 STATE SURCHARGES $6.63 STATE DBPR SURCHARGE 455-0000-208-0700 0 $3.98 STATE DCA SURCHARGE 455-0000-208-0600 0 $2.65 TOTAL FEES PAID BY RECEIPT: R8276 $271.63 Date Paid: Wednesday, February 27, 2019 Paid By: B & G PLUMBING, HEATING & AIR CONDITIONI Cashier: CT Pay Method: CREDIT CARD 076815 Printed:Wednesday, February 27,2019 4:20 PM 1 of 1 ..r ,wuur