1355 OCEAN BLVD PLRS21-0145 PlumbingPermit Application **ALL INFORMATION
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HIGHLIGHTED IN
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City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 (J /� }�
J Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: ��'LRSZj'(5145
JOB ADDRESS: 1355 Ocean Blvd. PROJECT VALUE $14,310.00
✓❑JEW OR REPLACEMENT INSTALLATION and/or EIRE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater
Other Fixtures 1 Water Treating System
❑MISCELLANEOUS
Chewer Replacement
❑Back Flow Preventer C 0 in C4S c , (\L__
❑Lawn Sprinkler System (number of sprinkler heads)
Erease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑Well **SJRWD Well Completion Form.Completed form to be submitted to the Building Department for final inspection. **
❑Other
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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:Josh Nussbaum Phone Number: / /7" Vz J"-- zr 7 2-
Plumbing
Plumbing Company: Mandarin Plumbing Office Phone: Fax
Fax
Co. Address: 3737 indiam Princess Rd City: Jacksonville State: FL Zip: 32257
License Holder: Steve Siegler State Certification/Registration # CFC1428316
Notarized Signature of License Holder 4mi.
The foregoing ' strumept was acknowledged before me this, A day o .4, j i 20,L( , in the State of Florida,
County of • ,
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o.'':'°�ae, PATRICIA D.HURD
Signature of Notary Public FA, ' LLaI�
i.,�;* Commission#HH 115411
N ''T r Personal) Known OR P oduced Id-ntification
o Expires August 8,2025 [ Y [ ]
~Po°,"�°°> °°"°'°Ilya Bodgo'Notary Service3 Type of Identification: �� ',4..A 1. :-_;
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Updated 10/17/18