122 6th ST PLRS22-0027 F.""'"iL`' PlumbingPermit Application **ALL INFORMATION
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"" City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 PL-RS ZZ -ccY2
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Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: R ' 22 —cc) 33
JOB ADDRESS: I ( 41 41— PROJECT VALUE $ ac=4-
❑NEW OR REPLACEMENT INSTALLATION and/or ERE-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 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: I-44r•r 1 Phone Number:
Plumbing Company: C- -.-- �/(...--7-+4),1.-•�� Office Phone: 7C,L( S'i°I-331(6, Fax
Co. Address: ,9-gSG -cPpl,.15 4 Cc-vc �'i�'I City: J ,A.-Jc State: R.. Zip: 2-•,-S--7
License Holder: Li„..-- ( CQ,./F State Certification/Registration# G Pte=(`-0-11`17
Notarized Signature of License Holder i�/�
The foreg instrument was acknowledged before t►is Z. day of IlkC1 20Zinthe State of Florida,
County of0 VLA
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Signature of Notary Public _ II OIL
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1: TONT COMMISSIERGER
ON
ersonally Known OR [ 1 Produced Identification /
*, .._ MY COMMISSION#�GG353178
ate. IIJ. ' .
-1-...,-•:ii EXPIRES:October 6,2023 Type of Identification:
"•'Fo'::�?e'. Bonded thru Notary Public Undervnitera
Updated 10/17/18