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Permit 149 Belvedere Street CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 INSPECTION PHONE LINE 247-5826 ��mr1;i1> Application Number . . . . . 09-00000381 Date 3/23/09 Property Address . . . . . . 149 BELVEDERE ST Application type description MECHANICAL HVAC ONLY Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 0 --------------------------------------------------- ------------------------- Application desc 1 cu lahu ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ BARON, MARCELLE TROPIC HEATING & AIR 149 BELVEDERE STREET Q/A:MARKS, CHARLES J. ATLANTIC BEACH FL 32233 750 MAYPORT RD. ATLANTIC BEACH FL 32233 (904) 241-1788 ---------------------------------------------------------------------------- Permit . . . . . . MECHANICAL HVAC PERMIT Additional desc . . Permit Fee . . . . 79 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 9/19/09 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 79 . 00 79 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Grand Total 79 . 00 79 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. V, MECHA�VICAZ PFR�YII� �r r CA- O: '�� Date: Property Address: Ag 9 1 yedere Owner: Ca o Jct c e- Kell Telephone#: -2Y7-SSSy Contractor: � a. /� ����'` Telephone#: 1 y/-179� Contractor Address: 7 SSc7 ,� s-r0� Fax#: -2 q/-217 Z In consideration of permit given for doing the work as described in the above statement,we hereby agree to perform said work in accordance with the attached plans and specifications which are a part hereof and in accordance with the City of Atlantic Beach ordinances and standards of good practice listed therein. Type of Heating Fuel: If other construction is being done on this building L Electric or site,list the building permit number: • — — / Gas: LP Natural _Central Utility ❑ Oil ❑ Other—Specify MECHANICAL EQUIPMENT TO BE INSTALLED NATURE OF WORK CY" Heat _Space _Recessed Central _Floor Residential or`*-Air Conditioning: _Room ✓Central Its Duct System: Material Thickness Pe- �p ❑ Commercial Maximum capaci /BOO cfin C1 Refrigeration ❑ New Building ❑ Cooling Tower: Capacity gpm ❑ Existing Building ❑ ' Fire Sprinklers:Number of Heads ❑ Elevator: _— Manlift Escalator (Number) Replacement of Existing System ❑ Gasoline Pumps (Number) ❑ Tanks (Number) ❑ New Installation ❑ LPG Containers (Number) (No system previously installed) ❑ Unfired Pressure Vessel ❑ Extension or Add-on to Existing System ❑ Boilers ❑ Gas Piping Cl Other-Specify _ ❑ Other—Specify LIST ALL EQUIPMENT AIR CONDITIONING,REFRIGERATION EQUIPMENT&CONDENSOR'S Approving Number Units Description Model# Manufacturer Ton's Agency 2-5,4,V 0#030 L- HEATING—FURNACES,BOILERS,FIREPLACES&AIR HANDLER'S Approving Number Units Description Model# Manufacturer BTU's Agency .r --o�Ge t r✓V��/ L �j Q..l� 2• s fit' v L TANKS Nominal Capacity Type Liquid Serial Approving How Many &Dimensions Contained Manufacturer No. Agency 800 Seminole Road•Atlantic Beach,Florida 32233-5445 Phone:(904)247-5800• Fax: (904)247-5845• http://www.ei.atiantic-beach.fl.us Revised 4%04 1Q.x , - 0 1S" CC #� 35, Oa J%' O yy $� 1a' i 'V 5 0' S�4+a C.wc. E� E�2E S M "Type .� �, a RAt14A*-%VE -s^ i DEPARTMENT OF BUILDING CITY OF ATLANTIC BEACH, FLORIDA PERMIT NO. O PERMIT TO BUILD ; THIS PERMIT MUST BE POSTED ON JOB I Date /23 19 77 j Valuation$ 25,760 Fee 67-00 00 This permit not valid until above fee has been paid to City Treasurer, and is subject to revocation for violation of applicable provisions of law. This is to certify that Jex• Equities & pone Exch. has permission to build a rest dentl a I { Classification S i ng le Farre# I Y done Owned by Edward Ashurtan an Lot 5 Block S/D seaspray House No- 149 E3elyeder e According to approved plans which are part of this permit NOTICE—ALL CONCRETE FORMS i AND FOOTINGS MUST BE IN- SPECTED BEFORE POURING. PERMIT VOID SIR MONTHS I AFTER DATE OF ISSUE x .4 00 4-10, ► Z rubbish and debris f olm/this work materialmust not be placed in public space, and must be cleared up and hadled away by either contractor or owner. R. C. 'Vogel i Building official. 4 i FOR OFFICE PERMIT DATE CONTRACTOR USE ONLY NUMBER, ,w, „t . PLUMBING ELECTRICAL i SEWER { Job #7 FOR OF�F•I�CE�USE ONLY Date------ - .....19-77 '0 c" CITY OF ATLANTIC BEACH Permit #...............•••"""'-Fee$.67..__.._...... Valuation $ !�, �(O.. FLORIDAH .. ouse #.... W-...�?.�''� cL- APPLICATION FOR BUILDING PERMIT Ul/, ,iJ QS ............................................................... 42 Application is hereby made for the approval of the detailed statement of the plans and specificatio herewith su mine for the building or other structure described. This application is made in compliance and conformity with the Building Ordinance of the City of Atlantic Beach, Florida, and all provisions of the Laws of the State of Florida, all ordinances of the City of Atlantic Beach and all rules and regulations of the Building Department of the City of Atlantic Beach, shall be complied with, whether herein specified or not. The Contractor or Owner-Builder who has been issued a Building Permit is automatically responsible to ascertain that all sub- contractors engaged by him are duly licensed in the City of Atlantic Beach,Florida. To prevent delay or embarrasment regard- ing intermediate or final inspections it is suggested that a list of sub-contractors be submitted to this office so that licenses can be verified. December Date..... , 19...7.6... Owner..........E-dward---Ashur an-----------------------------------------Address__P-..0._B.Q... ---Telephone No,.._aVE 35.Q0 Architect...... r Of e s s T onal De s iGns Address_75..3-O NIe rr i 11_ R d_.JMlephone No..._?44 r.16-54 Contractor Builder.Jax.Equities & Home EXChAddress..P-....Box 50003,s J9.X---Telephone No..._.24975600 LotNo.. ....�9-�------ ---------Block No. ----------------------.--Sub Division..........................................--------------------------- ........Zone----------------- BelVedere Street--------------------...--SideBetween.......Be.lve-dere.........--------and...................Daui�1...................Sts. 17,000 Single Home Valuation $..__._1_________________________For what purpose will building be used....... -.._._.._...._-.---------..Type of construction..Ngrw.BT'1Ck- S e e Plans Dimensions of Building----............................_......Dimensions of Lot__._.._:_. .......x_.. 00_.__._ ga..__...._.._ _.... 1 � ---------Size of Footings It .................. Size of Piers S e e P1 ans Size of Sills.See e...Plans See Plan hal--_-.S _.._...__.Greatest Sill Span in ft.__._.....................rype Roof......_-_P._-___. _ti hingles How will Building be Heated?-----------forced...he.a�...................Will Building be on Solid or Filled Ground?__...._SOl d•_---...-_-_••--- See Plans See Plans See Plans ff Size of Ceiling Joists------------------------------------------- Distance on Centers._..__..._...._._..._........._.............. Greatest Span.................................__._.__.._. It IT It 11 it R Size of Floor Joists-----------•-----------------•------------- Distance on Centers.......--- ------------------•----•------ Greatest Span........................................... ,p Size of Rafters.._See Plans Ii-------___------_._, Distance on Centers....._.. - It I 11--- ------------ -----------._, Greatest Span-------------------------------------------- " This rectangle is to represent the lot. Locate the building or buildings in the right position. Give distance in feet from all lot-lines and existing buildings. REAR LOT LINE Two copies of plans and specifications shall be submitted with application. Inspections required. 1. When steel is in place and ready to pour footing. W W 2. When steel is in place and ready to pour columns and/or lintel. Z See Plans x 3. When steel is in place and ready to pour beam. 4. When framing is completed. p 5. When rough plumbing is completed,and ready to cover up. W W 6. When septic tank drain field or sewer is laid but before it is covered. q q 7. Electrical inspection by City of Jacksonville. m 8. Final inspection. Note: In case of any rejection,re-inspection MUST be called for after corrections are made. FRONT OF LOT In consideration of permit given for doing the_work as described in the above statement, we hereby agree to perform said work in accordance with the attachgd•-planq�arid- specifications, which,are a part hereof, and in accordance with the building regulations of the City of AtlaA0 beach ,;- Signature of Builder_ .__�_ �✓-- ' �� Addr - Signature of Owner. x. ss.. ......�................ Lj TO 13 d;k" o"�'rz 4 149 Belvedere lh-1 U! < e. 'ev 'al A"i �l c 0 4 it. c a. xv�" a n 4�,'h t "s z f,"i 0e. v0vb t! 0 J&J-�w -e be iat' 1-aast. 500 a-:14y cu{� ii-14'.0i-l."24t d w e f s .tng XG Y d ,.A v SIA0 t.'i wr w i c-v c A 4 t.:E. C?r, ILl e.",th Si Tho o f D a df.&4'a and itach Service Pd.Gpe' -4sa ); AuQt bA� by ch;i? b'-for&" bo-4og coveref City Man&.get Thv '' Qad the abL"'Vc &Dd Ainderetcands that thiover any Goate alt y deta.ils to pie,"a-'s and comply c;C'vi it s'a Or t � DEPARTMENT OF BUILDING 3300 CITY OF ATLANTIC BEACH, FLORIDA PERMIT NO. i PERMIT TO BUILD THIS PERMIT MUST BE POSTED ON JOB Date 3/E$ 19 77 Valuation$ P i 1mmb i Diel Fee $ 11.00 I This permit not valid until above fee has been paid to City Treasurer, and is subject to revocation for violation of applicable provisions of law. This is to certify that DOft Hs "i s P1 it mbf ng CO. , I IIc. has permission to build tO I nstaI I 1 S1 nk, 2 tavatOrl es, 1 bath tub, 2 c1osetS, I shOwOr, I water" hebter, I dishwasher, i dIs o:>$1 and wa ng ne. Classification ISI#sI denti a iyonp Owned by Edward Ashurl an Lot 596 Block S/D– 5 House No 149 Bel vedere According to approved plans which are part of this permit NOTICE—ALL CONCRETE FORMS AND FOOTINGS MUST BE IN- SPECTED BEFORE POURING. PERMIT VOID SIR MONTHS AFTER DATE OF ISSUE ► -41 ► O Building material, rubbish and debris Zi from this work not be placed in public space, andd must be cleared up and hauled away by either contractor or owner. R. C. Vogel pp Building Official. i FOR OFFICE PERMIT DATE { USE ONLY NUMBER CONTRACTOR Y PLUMBING { ELECTRICAL SEWER WATER - 6 r.- 3360 WMAR ?LUM KITTAY i Vuo inv ; TUE . pums 2, On SET DNA TGTAn SIXTURu. 211DZ AW ANEMPTCAYM lont whow 0 plan Act dssoripzien cite and luse"im 01 all inn OOP on, vent plycz , 071 She nunM W� 10WHOP Q: Q3 fighusn" , ( in acoordanow w0h OrdInEugs "I, jyj If Os city of • c BOOM, plurtdu) aw t)f' sn'c"l-im e"�L 2atich and be approvuy by rhe Vlnmblng lnspeotvx APprovad by_ FRAL X —ARRTIRT CATE ISSUED ... ;� .<-r,y -., -...-. ..• �.... .�s.+s.....+'_.tea .,... _ .�,p� ......R+Fs.:L.s^3 ta:�.« .+e*;..s,,..,i�_.S�,ss..,;..�yr..",5;• .^µ...;"yip .fig'.,. ;''- +'9F . r I 1 _�-- ;' 1 A T DEPARTMENT OF BUILDING 9678 CITY OF ATLANTIC BEACH,FLORIDA PERMIT NO, PERMIT TO BUILD 1921 THIS PERMIT MUST BE POSTED ON JOB ninn I Date Apxi1 32, 19as Valuation$ Fee 1 no fee This permit not valid until above fee has been paid to City Treasurer,and is subject to revocation for violation of applicable provisions of law. This is to certify that DAVID -,TERM 266 South Roscoe Boulevard Ponte Vedra has permission to b i rgn"a two large__spind,YYpine tree-, in rear yard, croudiag cedar- tr*e Classification Zone Owned by Mrs Aron Lot Block S/D House No. 349 Belvederre Street According to approved plans which are part of this permit I NOTICE—ALL CONCRETE FORMS AND FOOTINGS MUST BE IN- SPECTED BEFORE POURING. PERMIT VOID SIX MONTHS AFTER DATE OF ISSUE 4 -► 4---- 0 O Building material,rubbish and debris 4 from this work must not be placed in public space, and must be cleared --up,,and hauled away by either con- tnt` `r or owner. �i ng Official. FOR OFFICE PERMIT DATE CONTRACTORS USE ONLY NUMBER PLUMBING ELECTRICAL t SEWER I l WATER low '�°""" CITY OF ` 716 OCEAN BOULEVARD P.O.BOX 26 ATLANTIC BEACH,FLORIDA 32233 TELEPHONE(904)249-2396 APPLICATION FOR TREE REMOVAL PERMIT DATE Applicant NAMES 6qrk-s2 ADDRESS ( y/� Owner NAME An C,rnv% ADDRESS 1 Lll ?e- !(jC- cr( , Location of tree if different from owner's address : Reason for Removal : c�c 5 d;,, r 4 G aSC Los( rh 4 rcpCo�— Ct dr Rear Lot Line a� a� indicate a a possition of tree on 0 0 0 lot a a a� a� b b .r., .T, Front Lot Line APR 2 z 1988 Building ffi 'al Building and Zoning 4 .moi a �s ! YLQ JG✓V"(.c -0 gyp IrB(2wov-\ �t IJC (�/Gderc , 6132 DEPARTMENT OF RUILDINQ CITY OF ATLANTIC BEACH x� ,�- -: FEI" I9'' INFORMATION, ,'._�.�'.._ .�.. __ "I.sCATOH INFORMATION -------- :613Z - 513 AddrO�msx 9' BRLVADERE" STREET Type t dE-4,00F ATLANTIC BEACH, FLORIDA 3223 MCS " f Works NEW : GAL DESCRIPTION ---- ------ Typq 1606 I~RAMS Lot: - ` Ek 2 Section t "Posed t G ;F'AtIiILY Tra�rtx�hatp r RNG g 0 �r C Dow s O Subdivision., "` Ottt± lu+ t, fit).UC7 I'lioi v Cast t. $0.00 -;T, °Fi t .2. r0 I 1111 /! 2 ROOF WITH NEW FISERGLASE SHINGLES, AND FELT .,.`... PiATTI N -� � - APPLICATION FLEE t PERM I $22.50 pry, RE. STREET WATER IMPACT_ FEE `Cti F flRIDA SE IMPAC FEE $0.Cl g /� �,( 2 r .. IS'00 A6 A• N Gk$—H. R. S- $Os'00 . NFORMA�TI it - RADIAN GAB -. SX $0. 00 E E :; • « ": . i`iNG t WATER T'APCt,Q0r Adder .. . '' SEWER . ._ q. .r n . wt a: _ PL tilybR,AULIX HARE �Q. SIO . Type z 0 RE-INSPECTFEE .E)fl m SEC. H_ HFACT FEE � 0400 �cJ 7 NOTICE-ALU CONCRETE FORMS AND FOOTINGS MUST BE NSPECTEp BEFORE"POURtNQ "h PERMIT VOIQ StX MONTHS AFTER DATE Ofi;ISSU!` BUILDING MATERIAL,AURBISH AND DEBRIS FROM THIS WORK MUST NOT PLACED IN PUBLIC SPACE AND MUST BE CLEARED UP AND HAULED AWAY BY OTHER CONTRACT©R:OR OWNER � ( •y �y T P • t. i f'�{f K ma *'FA!l.URE TCS COMPLY WITH THE MECHANIC ' L��N � RE TEN THE P oPER•r�r wNEa:PAYTVG TWICE I`aI BUIIL0111 G NTS.,, , . L ISSUC-D ACCORDING TO"APPROVED PLANS WHICH ARE DART OF THIS PERMIT` AND SUBJECT TO REVOCATION FOR VIOLATI(yN OF APOLICAB4E,PAOVISIONS.OF LAW. ATLANTIC BEACH BUILDING DEPARTMENT 8Y: CITY OF ATLANTIC BEACH PERMIT APPLICATION ROOFING Owner(s) : Address. / 1 ta 'L Vt� :%!' _ Phone: ' Lot # Block or Unit # Subdivision _ nn Contractor: Address: :1, , �' �} .1 �`s.. Phone: State License No. Describe work to be done: c"Je� Materials to be used: j l kc Z 6-LI) ssy r'\jPJ--6f*4 Signature OWNER: Date: Signature CONTRACTOR: £__ 09 DEPARTMENT OF BUILDING CITY OF ATLANTIC BEACH . ..'» P N '0 MA ` OM - .»------ �OCATIO 11 I I�O ��O rm I mer, SS Address. 1 j BIV D `Type: H't1TT►T IO i' ' ► Imo" "iDA 32233 or SAVO, 0Oustr. TypeWPOD PRAME T.c+t 598 a k1g, $00tibn: ft5 ►posed Use, SxIIiT t 1 Code,: 0 Bubctivi 'L'ISA imatod value m rov. Cost : Total ees:z �25 .I�t1 mtxt d. ' $25.00 4/95 4r�1W ...a 00°. } TER° r �j. DA�P01, ORL I� 2 C . I�`t91MAT ON . . .» It2D4N M •� ,< # M1 w Nerve: 0 T" NSRk CAIT )1, 41 deee: � .JVV*dos License'. Type; - I Sed It `Tmpjkc71,1 ,2� OONsTwOlt, amw�f13 w NOTES, NOTICE—ALL CONDRETF-I=dAMIA AND FOOTINGS MUST Of.INSPECTED BEFORE POURING PERMIT VOID SIX MONTHS AFTER DATB OF ISSUE ' BUILDING MATERIAL,RUBBISH ANIS DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC.SPACE,AID MUST . . CLEAIEI UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER "FAI.URE T C1UfLYYH THS MECHAIUlC'S LIEN LANK . RESULT THE RC)PERTY OWNER PAYINGTWICE FQRTHE 9t ,bk MpR E E t i„ ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUE3JECT TO REVOCATION t=OFI h �' �, V#OLA`EION OF APPLICABLE PRQVISIOIVS OF LAW. `k u r ATLANTIC BEACH BUILpiNG P RTM1ENT 0000IS144d 4t sm,00 I� Wit 4/0�/�01. 0043150 By, .� r � a .911 �p R p 31995 CITY OF ATLANTIC BEACHR�ild'+ng and �0n�ng PERMIT APPLICATION REMODEL, ADDITIONS OR ALTERATIONS DEMOLITIONS Owner(s): �n�dtL� Address: l`�`> L�for n� S; Phone• c4 Lot # {� '�' Block or Unit �° Subdivision: Contractor State License 3-)'i:-7 Address: o�f / i�'1✓��Ci�"� �y��� �%� Phone No: Describe work to be done: , J , � y Present use of building: Valuation of Proposed Construction: ��'�'�� Proposed use: Is this an addition? If yes, what are the dimensions of the added space: ft. X ft. Will the added area be heated and cooled? New electrical (or increase)? New plumbing fixtures? New fireplace? New Heat/AC?,w_ SUBMIT THREE COMPLETE SETS OF PLANS, INCLUDING SITE PLAN, SURVEY, ENERGY CODE FORMS, NOTICE OF COMMENCEMENT, AND OWNER/CONTRACTOR AFFIDAVIT, IF OWNER IS CONTRACTOR. t / X Signature OWNER: t� � ;� �✓ / ��' t `r Date: Signature CONTRACTOR: Date: License Supplied: R�V��? P BSvice�+ Q ASR A ' pFICE -. Liability Insurance: Worker's Compensation Insurance: j\VR 1 B9 G` w,6X e of ON NG ev- ��e a�9r'Poke \Or1 JCS. D ; e oq,6 ��o� p,ec ( i Ppb Fb \r1 Spec Oo°�Q e o� O�°ee wA�r9� g r,i rt F<a Poo we" .. ....wariw..+a.�.r.r�.m...www•ww+....+rr•►...www.irw.�w!Tr.+r..:�.....+......w.+rwr.•......•++nr....►�.•.r....`�... +........w...+...w..�...«...-..�..�......... +. MAP �H 0"l Is as �U�V�`t' �� �s RCCORDEO IN PLAT EOQK —!-:_.....PAGEPUBLIC • GF PUBLIC RECORDS OF OUVAVl:1. CO. Ft_,1 FOR •IG�C,iJ;�:c�tJ�lft_t i- i ,'yt > e. �IC�fV1t= - C.�' .I-aF.1.ir _ v4v'j ) '4 3T 0 "• oil: r ... .. . A. ! 49 ol �.3 r'�.C.7. •t•rJ �. tS,f G':t pJc��cc ?R OFF l CJ 7 (•n 1 QJ t.L7 T &t 4- 4pt� �Y vi ?, i4L-CVh P IJC:)V 'tet lq*l-1 UCD tq'7'7 i� MA1O�NT A�yamt:�iAR1i e•u. !rl t+ 1.tAlO tl+k 1: Ah A_ APPLICATION FOR WATER CUT-IN TO THE CITY OF ATLANTIC BEACH: Application is hereby made for 3/4' Tap water cut-in at the following address for i unit(s). Cut-In charge of 85.00 Street No. 149 Belvedere Lot 598 Block Subdivision Seaspy Ordered b Owner 12 IV -, Mailing Address P.O. Box 5003, Jax. Date Account No. Meter No. Date Installed o j41-* �7�� / J NJ. It CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD ATLANTIC BEACH,FL 32233 INSPECTION PHONE LINE 247-5826 0 l lit Application Number . . . . . 10-00000248 Date 3/08/10 Property Address . . . . . . 149 BELVEDERE ST Application type description PLUMBING ONLY Property Zoning . . . . . . . TO BE UPDATED Application valuation . . . . 0 ---------------------------------------------------------------------------- Application desc 1 SHOWER PAN ---------------------------------------------------------------------------- Owner Contractor ------------------------ ------------------------ KELLY STEVEN' S PLUMBING INC 149 BELVEDERE STREET 297 N ROSCOE BV ATLANTIC BEACH FL 32233 PONTE VEDRA BCH FL 32082 (904) 285-9320 ---------------------------------------------------------------------------- Permit . . . . . . PLUMBING PERMIT Additional desc . . Permit Fee . . . . 62 . 00 Plan Check Fee . 00 Issue Date . . . . Valuation . . . . 0 Expiration Date . . 9/04/10 ---------------------------------------------------------------------------- Fee summary Charged Paid Credited Due ----------------- ---------- ---------- ---------- ---------- Permit Fee Total 62 . 00 62 . 00 . 00 . 00 Plan Check Total . 00 . 00 . 00 . 00 Grand Total 62 . 00 62 . 00 . 00 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. PLUMBING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph(9-p04) 247-5826 Fax (904) 247-)5845 .TOB ADDRESS: y 01 &,L V o e e r_ S__T �'� c c G. 3 ? 2_�3° PERMIT# NEW OR REPLACEMENT INSTALLATION: Project Value $ 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 RE-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 ❑ Grease Interceptor(Trap) gallons(Requires 3 sets of plans) ❑ Lawn Sprinkler System-Number of Heads ❑ Well ** SJR WD 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. Property Owners Name_ ,il 1J 1 c: e f Phone Number 2J 3 Plumbing Company - /V S 104-'M1 11'? !:�_Office Phone 2 "�5_- Fax 'Q>:5--30'�- Co. Address: '2=r -7 Al Jar c, R (v Al City �, U, ��,�, State Zip' i License Holder(Print): (i vV, State Certification/Registration# Notarized Signature of License Holder ................some.....................� .. DIANE STOVER e Sworn and subscribed before me this- --day of CLyCjn 20 E ,. a,'r Corr x4aoiGGO C xplreZ � s�rvzotr Signature of Notary Public Fbdde NoWyAw., wu■nuuuuumuuuo.u.wuuu.ccsv_-..