50 SEMINOLE LANDING PLRS22-0174 Plumbing Permit Application **ALL INFORMATION
rs'1��1f�,. �� HIGHLIGHTED IN
` i City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 [�L RS ZZ- 6 I "7 4
"`'r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: 27,_— b2%c0
JOB ADDRESS: . ---v -5-eim i A/,-JC Lc:.aE1n.4 /(,r) PROJECT VALUE $ / 1"' ' r,
2 EW OR REPLACEMENT INSTALLATION and/or ERE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub / Septic Tank & Pit
Clothes Washer / Shower Z
Dishwasher / Shower Pan t_
DrinkingFountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory 3 Water Heater
Other Fixtures ater 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: CII'-,,�i// ,h.1 T-(—<, "F—FICeitc - Phone Number: I 'i y—5.6 af'
Plumbing Company: e,LG,e/ires ,.L„_ Office Phone: 3 g ,.... -4e.0;- Fax
Co. Address: 2 3 s/ 4444.. -/ City: State: P' Zip: .5 zz1 U
License Holder: '�fi,c- C'a2,ire/a(-✓-. State Certification/Registration# C 6•52.6/S
Notarized Signature of License Holder
The foregoirti. instrument as ac owledged before me this ZZ day of C)J , 20Z the State of Florida,
County ofd\/' 1
Signature of Notary Public c-----__ G CT
w rn. •WI.7�11.r VI 11 Z -
• t t ;: TONI GINDLESPERGER [ ] Personally Known OR [ ] Produced Identification
M1'ODMMISSION#GG353178 Type of Identification: L
. - EXPIRES:October 8,2023
°f n s,.Banded Tbru Notary Pubic Unde wd ers Updated 10/17/18