1813 Seminole Rd PLPP21-0041 re-pipe 9 fixtures permit (2) e0
Plumbing Permit Application *'ALL INFORMATION
HIGHLIGHTED IN
Ai 0
,� City of Atlantic Beach Building Department GRAY
800 Seminole Rd, Atlantic Beach, FL 32233
`u'.' Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: Cdit1/T 2/ -ODyj
JOB ADDRESS: I gf 5644/in de id PROJECT VALUE$41, SOO .O
%i EW OR REPLACEMENT INSTALLATION and/or 126-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank& Pit
Clothes Washer 1 Shower
Dishwasher _ Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet 2
Hose Bibs .1 Urinal
Kitchen Sink 1 Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Z Water Heater 2
Other Fixtures Water Treating System
❑VIISCELLANEOUS
❑Sewer Replacement
❑Back Flow Preventer
❑Lawn Sprinkler System (number of sprinkler heads)
❑Grease 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 /FP/ 2epi�P /1e,/ISC t,.'/t", /81,� g6/06c�P, w/
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: Ia al/)12j t/,`//els Phone Number:
Plumbing Company: .*y/e5 ‘5,' ,�fh J lv/'70' Office Phone: 214) -111,3/ Fax
Co. Address: /513 7 Pea/kic✓7 cd City: J6X 13ec,th State: FL. Zip: 3.2,Z5 D
License Holder: , *yJe 5 ,�7/,-►, Ik7 State Certification/Registration# LFL PIA. •6 2
Notarized Signature of License Holder
The foregoing instrument was acknowledged before me this I 0 day of A.100 QNI(O(20 al, in the State of Florida,
County of fbvt- 1't
Signature of Notary Public ,1 411111.
., IIT
'° JENNIFER JOHNSTON ✓/
'• % MYCOMMISSION#HH 057579 [ ] Personally Known OR [ roduced Identification
�'.a.'"'••W JE_XJPIRES:October 27,2024
' y Type of Identification: FL �-
•'EOR FL p_W��lW Notary Pub&Undefwrfte1
^� _ - Updated 10/17/18