Permit 1665 Selva Marina Drive~_ ~s`-'`1'~~re,~ City of Atlantic Beach ~` -
\~ ~ _~S1 Building Department ~~py~,,,y
~„ t 800 Seminole Road ~ Y ~_~
j -`~~~ Atlantic Beach, Florida 32233-544 ''~~`' ~ ~ ~
~ ~` Phone (904) 247-5826 Fax (9 -5845 ~ ~
"'°~Jai yr E-mail: building-dept@coab.us ~ ~ ~~~
City web-site: http://www.coab.us ~~'~.~~
~-PPLICATIOIV REVIEW ,p-
//// /J~ C
Property Address: /C~~ S ~!/~- dr///LG1l~ ~r,
Applicant: ~~0~7`~ /~/~~
Project: l/UC~
APPLICATION NUMBER
(To be assigned by the Building Department.)
G-~~3
Date routed: ~~~ ~J
CKIIVG I=ORM
Department review required Yes No
Building
Planning & Zoning
Tree Administrator
Public Works
Public Utilities
Public Safefiy
Fire Services
.. _.
Review fee $ Dept Slgnafure
Other Agency Review or Permit Required Review or Receipt
of Permit Verified B Date
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St. Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review: ~pproved. ^Denied. II
(Circle one.) Comments: i
BUILDING
PLANNING & ZONING
Reviewed by:
~//~i Date: ~~/U
TREE ADMIN.
Second Review:
^Approved as revised.
^Denied.
P ORKS omments:
Z /o
PUBLI SAF Y Reviewed by: Date:
FIRE SERVICES Third Review: []Approved as revised. ^Denied.
Comments: ~
{
Reviewed by: Date:
Revised 05/14/09
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph (904) 247-5826 Fax (904) 247-5845
JOB ADDRESS: ~~p G ~ ~G/1/~ ~~Q !', i?r.~ ArPERMIT # ~~ _ G
NEW OR REPLACEMENT INSTALLATION: Project Value ~
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub
Clothes Washer
Dishwasher
Drinking Fountain
Floor Drain
Floor Sink
Hose Bibs
Kitchen Sink
Laundry Tray
Lavatory
Other Fixtures
RE-PIPE:
TYPE OF FIXT URE
Bathtub
Clothes Washer
Dishwasher
Drinking Fountain
Floor Drain
Floor Sink
Hose Bibs
Kitchen Sink
Laundry Tray
Lavatory
Other Fixtures
MISCELLANEOUS:
Septic Tank & Pit
Shower
Shower Pan
Slop Sink
Three Compartment Sink
Toilet
Urinal
Vacuum Breakers
Water Connected Appliances
Water Heater
Water Treating System
QTY TYPE OF FIXTURE QTY
Septic Tank & Pit
Shower
Shower Pan
Slop Sink
Three Compartment Sink
Toilet
Urinal
Vacuum Breakers
Water Connected Appliances
Water Heater
Water Treating System
^ Sewer Replacement ^ Back Flow Preventer ^ Grease Inter/ceptor (Trap) allons (Requires 3 sets of pla
^ Lawn Sprinkler System-Number of Heads d Well y~ ** ~~'~ / b a ~ PSG
** 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.
Property Owners Name ~~ fi /'7%/~~G~/ _ Phone Number
Plumbing Company /%~ /~ ~ iv % YI'~, ~y Office Phone Z k ~d'fU~ Fax 2?d Z Z~ ~
Co. Address: // 7 7 ~f~G, thy- /~/v ~ City ~~14.,/S'~C ~3c~ State ~ Zip J ZL 3 J
License Holder (Print):
lljotca~^r'zed
P E5 1Nhy~U 634126 S
Ex ~a 2ot1
Bontled Thru Notary public UnderwritersC
cr.,-~
and subscribed before
of Notary Public
tate Certification/Registration # / ~~
of
20 ~~
.S r~`l yf
of ! G'
J - ~~
%'• •l
.. __ ~S'
~'`+='t JiSI>r
CITY OF ATLANTIC BEACH
WELL PERMIT APPLICATION
Date ~S' 2 r~
Owner's Name: ~4J~ ~l~'hc;~~V Address: ~~' ~ 5" ~'~"'~ ~'`~ ~ tr,7l~~ /.~
Well Address (if different than above): -~~'~~~'
WeI1 Location on Property (i.e. northeast corner, etc.) =S~?~~"~~ G~.~S~~ ~~~ ;~ ~~-
Well Installation Contractor: ~~~'~ ~7N 1~~~+~i
Contractor License No.: ~ ~ ~ ~ Phone: Z~.s~~.s'c~s FAX: -~ ,7~7 Z Z.,~' L~
Contractor Address: ,r~ 7~ -:~~~ ~..- /~/'t%'
Check Use of Well: Domestic Irrigation ~ Other !' ~''
r ~ f~~ ( l ~ L7
Estimated- Well Depth: ~~~ Casing Depth: t 3~~ Screen Interval from to
Well Diameter:~_ Casing Material '' ~% ~--
Is address currently connected to the City water system? ~~ z
Is address currently connected to the City sewer system? ~~~
Has a Well Permit been obtained from the City of Jacksonville? :%~ Permit #
Does the well require a permit from the 5t. Johns River Water Management District?
(Not required. for wells under 2-inches diameter installed by resident or wells under 6-
inches diameter if installed by licensed well contractor). ~~~~}
If permit is required, note Permit Number and attach a copy.
NOTE: WHENA WELL IS INSTALLED ON YOUR PROPERTY, YOU MUST
INSTALL A REDUCED PRESSURE ZONE TYPE BACULOW PREVENTER ON
THE CITY WATER SERVICE. ON THE CUSTOMER'S SIDE OF THE METER.
THE BAC%FLOW PREVENTER MUST BE TESTED BYA CERTIFIED TESTER
AND A COPY OF TH'E RESULTS SENT TO THE PUBLIC UTILITIES
DEPARTMENT.