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PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233 1,2
Ph(904)247-5826 Fax(904) 247-5845
JOBADDRESS: . HYd "11c. 614 , PERMIT
NEW OR REPLACEMENT INSTALLATION: Project Value$ b5V. 00
TYPE oF FixTuRE QTY TYPE oF Fwum 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 i:1 Back Flow Preventer o Grease Interceptor(Trap) gallons(Requires 3 sets of plans)
* Lawn Sprinkler System-Number of Heads Ej Well
** VR WD Well Completion Form. Completed form to be submitted to the Building Department for final inspection.
El 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.
Pp
Property Owners Name lm�/& A r 1'e 1-f Phone Number37d-0 33S
Plumbing Company CHRISTY FIRST COAST PLUMBING, INC Office Phone 247-4419 Fax 249-4660
Co. Address: PO BOX 50446 City JACKSONVILLE BEACH State Fl,Zip 3 2240
License Holder(Print): BRIAN D. CHRISTY State Certification/Registration# CF C056487
Notarized Signature of License Holder
Sworn and subscribed befo �s
C)&A SS #
9 7Z 6
Signature of Notary Public t2