340 2nd PLRS22-0021 Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 P L RS Z Z -CD2
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: R C Sa•1 -U 31(
JOB ADDRESS: M.°° and AV e,ru1.J PROJECT VALUE $ C I�Sc' "
❑NEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub I Septic Tank & Pit
Clothes Washer a Shower 3
Dishwasher l Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet to
Hose Bibs L} Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory 1 Water Heater
Other Fixtures Water Treating System
❑MISCELLANEOUS \
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
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: k) • \ Phone Number:
�1'
Plumbing Company: C u V iA5 l\t Office Phone: q0`/--g(" ' 5 7 Fax
Co. Address: 1)'(- City: 6 ')3
State: Zip: 321L Z 6
License HolderTM00-1,-S atAx-Kp4-a N State Certification/Registration # cFc14.2-/35
Notarized Signature of License Holder
The foregoingynstrument(was acknowledged before me this /8 ay of rP b , 2024-in the State of Florida,
County of
Signature of Notary Publi Q ��
Tota;e; [ ] Personally Known OR [ ] Produced Identification
�?•""`fid•; NDLESPERGER
MY GpI,f'isSIONUGG3s3flg Type of Identification: L
,��►�'� EXP RES:October 6,2023
•FeF fa r, f u Notary Public UndetSvtfters Updated 10/17/18