2093 BEACH AVE PLRS22-0183 tPLUMBING RESIDENTIAL PERMITiili PERMIT NUMBER
(1---7'2,?,,
CITY OF ATLANTIC BEACH PLRS22-0183
V~ 800 SEMINOLE ROAD ISSUED: 12/13/2022
\ `''3 9%' ATLANTIC BEACH. FL 32233 EXPIRES: 6/11/2023
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLORIDA BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
that may be found in the public records of this county, and there may be additional permits required from other
governmental entities such as water management districts, state agencies, or federal agencies.
JOB ADDRESS: PERMIT TYPE: DESCRIPTION: VALUE OF WORK:
2093 BEACH AVE PLUMBING RESIDENTIAL BACKFLOW PREVENTER $60.00
TYPE OF REAL ESTATEZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: I GROUP:
169720 0000 NORTH ATLANTIC BCH
UNIT 3
COMPANY: ADDRESS: CITY: STATE: ZIP:
HOLLINGSWORTH
PLUMBING COMPANY 8242 CIRCLE ST S JACKSONVILLE FL 32216
OWNER: ADDRESS: CITY: STATE: ZIP:
TURNER MICHAEL D 1270 EAST COAST DR ATLANTIC BEACH FL 32233
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IfN
YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
LIST OF CONDITIONS
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 1 $7.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
TOTAL:$66.00
Issued Date:12/13/2022 1 of 2
•iy,Iy
Plumbing Permit Application **ALL INFORMATION
':,%' �-�,� HIGHLIGHTED IN
' , City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 Q
j
Phone: (904) 247-5826 Email: Building Dept@coab.us PERMIT#: 1 1J Z 0133
JOB ADDRESS: 9CA 3 t3eas h live,/1441a14,-C &tae ti/Q, 30/49i'ROJECT VALUE$ 60,OB
❑NEW OR REPLACEMENT INSTALLATION and/or ORE-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
X 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: ,ocie /�o// o�-Vj Phone Number: 39-594 443,
Plumbing Company: /./o//,,,,Asw.r ki it9km6la 6.►•rp7 LLL Office Phone: 9 /-993, Fax
Co. Address: 6,p'/ cm,( . City: -- z-,..0.7.v State: /=/ Zip: ,tea/‘
License Holder: Byer' /,/o//n swo ii-1,‘ State Certification/Registration# Cr</93/57'7
Notarized Signature of License Bolder
The foregoi '" tru�ment w s acknowledged before me this 1:3 da Q, , in the State of Florida,
County of � = �V���
Signature of Notary Public 9�J
ilf
°F;c: TONIGINDLESPERGER �[ 1 Personally Known OR [ 1 Produced Identificatio ,
11 MY COMMISSION#GG 353178 Type of Identification: , 1
is i EXPIRES:October 6,2023 —
L'V ° Bonded ihru Notary Public Underwriters Updated 10/17/18
City of Atlantic Beach—BACKFLOW PREVENTION ASSEMBLY TEST REPORT
902 Assisi Lane Jacksonville, Florida
da 32233 Phone: 904 247 5886
Name of Premises: I Account No:
Service Address: 49 Cf)3 beach AveMoil/ �11 oil,e i3eac tI t/, .3e2..7.33
Mailing Address(If Different):
/
Contact Person: Y , k? 7 /rne( Phone Number: got/- qr.)? 3-6 016
Type of Service: I Process Fire I Domestic (g Irrigation ❑Other:
Type of Assembly: ,`i Manufacturer: t-e bCO
Model: 25(v 0 Serial No: (0 75107. 3
i i)
Size: / Location:_44 :0-E Ot'�/'
r.)al' 'f( -
Gauge Manuf: (MT 0vJE5+ Serial No: 014 I I(9.75 0 Date Calibrated/Verified: it)/c q/
Check Valve#1 Check Valve#2 Relief Valve PVB or SVB
Closed tight ,® Closed tight Opened at ❑Air inlet opened at PSI
at -7, 2 PSI at ic-3. PSI PSI ❑ Did not open
❑ Leaked ❑ Leaked I Did Not open El Check Valve Held at PSI
❑ Leaked
..
❑Cleaned only ❑ Cleaned Only ❑Cleaned Only ❑ Cleaned Only
Replaced: Replaced: Replaced: Replaced:
❑ Rubber Kit 0 Rubber Kit 0 Rubber Kit ❑Rubber Kit
❑ CV Assembly 0 CV Assembly 0 CV Assembly ❑CV Assembly
L 0 Disc 0 Disc 0 Disc 0 Disc
';a 0 0-Rings 0 0-Rings 0 0-Rings ❑0-Rings
J 0 Seat 0 Seat ❑ Seat ❑Seat
0 Spring 0 Spring 0 Spring ❑Spring
❑ Stem/Guide 0 Stem/Guide 0 Stem/Guide ❑Stem/Guide
❑ Retainer ❑ Retainer ❑ Retainer :Retainer
❑ Lock Nuts 0 Lock Nuts 0 Lock Nuts :Lock Nuts
❑ Other,Describe 0 Other,Describe 0 Other, Describe ❑Other,Describe
Closed tight at Closed tight at Opened at �S PSI Air Inlet PSI
7 c PSI a . PSI Check Valve PSI
Remarks:
I certify that the data in this report is accurate.
Tester Name (print) : le- ,n wo( GI Date: /(-2//3/a=9-
Tester Signature: Phone: gCz/- 89 y- 99/3'
Affiliation: Ocnl nG r Cert No.: -31( - ad--i 6i,5",
Tester Company: Ne%/ y5 rill /94,,n t,pa e7cm77„77 zit Address: li•, .',7 ,.' /C rS . • a _ a16
THIS ASSEMBLY PASSED ❑ FAILED
Email completed form to Ebrown@coab.us/jdsmith@coab.us