640 BEGONIA ST PLRS22-0019 plumbing � Plumbing Permit Application **ALL INFORMATION
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"" City of Atlantic Beach Building Department GRAY IS REQUIRED.
4 800 Seminole Rd, Atlantic Beach, FL 32233
<-4N-7 .....-r'
- Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:ff4_
JOB ADDRESS: .. ,6 2& 6A//19 PROJECT VALUE$ 5-00i 1 v
53NEW OR REPLACEMENT INSTALLATION and/or ID RE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub _Z__ Septic Tank & Pit
Clothes Washer / Shower
Dishwasher / Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink -- Toilet Z--
Hose
Hose Bibs 2 Urinal
Kitchen Sink
--/— Vacuum Breakers
Laundry Tray —' Water Connected Appliances --
Lavatory 2 Water Heater /
Other Fixtures Water Treating System
❑MISCELLANEOUS \�
❑ Sewer Replacement
❑ Back Flow Preventer
❑ Lawn Sprinkler System (number of sprinkler heads)
n 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
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 regulationk
constructiontior thke
performance of construction. f L�
Owner Name: f Ke 0/tw 1 C /�l_ / 9 /i'2'"' Phone Number: / 7✓ 9 6
Plumbing Company: /9gee-) / i '-' lal5ffice Pine: / 7-9" °U Fax 26 -1T 1"
Co. Address: Vj?5/ (' 1i4, ,J City:191"/e P 1 Statef Zip: Y2f i'---
67Cciefi?C /7 '7'27?--7 4, G c
License Holder:
State Certification/Registration# � C �yZ��l/
Notarized Signature of License Holder 7::;271- Z.._ r
The foregoing-Ment was cknowledged before me this /( day I L , 20 2,n_the State of Florida,
County of fC).._ I
Signature of Notary Public m
9 '
.. TONIOINDLESPERGER I
*; 1,; MY COMMISSION II GO 3531781 [ ] Personally Known OR [ ] Progyced Identification
'f'- I EXPIRES:October S,2023 Type of Identification: l�
"•„: Bonded Nu Notary Public Underwriter I
Updated 10/17/18