340 1st St PLRS22-0185 0_,A,y;: Plumbing Permit Application **ALL INFORMATION
JS r - HIGHLIGHTED IN
,'} City of Atlantic Beach Building Department GRAY IS REQUIRED.
�" 800 Seminole Rd, Atlantic Beach, FL 32233
�''s"r Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#._kS22--O(8S
JOB ADDRESS: -$ if
D PI" sJ PROJECT VALUE$ 21fob `cr'
❑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
El 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: kti•7 k 16 i Phone Number: /0`l -6 c `/fa.
Plumbing Company: ` ^7 /t (' -1 P`c, s.r6,J Office Phone: Yo - Z FL -00/7 Fax - ±
Co. Address: 3 [ 1 S #./.‘ /-2.,..,i 4. City: -I4 L- SU ✓4c State: FL Zip: .1,2-2- —
License
21 `License Holder: r��7 ��o/vState Certification/Registration# 4-1=e-- e'c 7gS /
Notarized Signature of License Holder 44-
-
The forego' ' trument as acknowledged before me this 1day )ems , 202,9rrthe State of Florida,
County of
Signature of Notary Public (------
talo TONIGINDLESPERGER
Personally Known OR [ ] Produced Identification
MY COMMISSION#GG 353178
't1-4 •"
..W,..,= EXPIRES:October 6,2023 Type of Identification:
"•"'Fov F R`•'' Bonded'Wu Notary Public Underwriters
Updated 10/17/18