775 AMBERJACK LN PLRS22-0168 Plumbing Permit Application **ALL INFORMATION
�� HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:PL -RS2 Z-6I7�
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JOB ADDRESS: 7 7C- 4,-”,b,- /t� . LI-A PROJECT VALUE $ 2 Yq D
Giff<IEW OR REPLACEMENT INSTALLATION and/or 111 RE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub _CI Septic Tank & Pit
Clothes Washer Shower
Dishwasher I Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet 2_
HoseBibs 2 Urinal
Kitchen Sink / Vacuum Breakers 2___
LaundryTray Water Connected Appliances
Lavatory . - /*------ Water Heater ___L_
Other Fixtures Water Treating System
I
❑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: / b J c 1 J,e•'i`,-es Phone Number: `ib c - lci3 13y 6
Plumbing Company: S/i,9WN Off '5 (A/r,))15 (Office Phone: gUY-3Y3 363/ Fax
Co. Address: L 7/6 1/415 Pe- Kalb l}✓z - City: ..:14?/ State: r^L-Zip: 3 2 Z c 7
License Holder: 5keii✓1/4/ 6". Orr �� A [/ — State Certification/Registration #Cl L O5 6 g 1 3
Notarized Signature of License Holder
The foregoi " ststrument was acknowledged before me this/21 da • L. Q) , 202 .n the State of Florida,
County of I��0 V"c _r /
Signature of Notary Public- - fr C.—
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��. TONIGiNOLESPERGER [ ] Personally Known OR [ ] Produced Identification
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ION#G,2023 a Type of Identification: 1= /
=,�.�4 s: EXPIRES:October 6,2023
f{ °dt`°Q Bonded Thru Notary Public Underwriters Updated 10/17/18