Permit Plbg 1767 Seminole 2012 :` :° CITY OF ATLANTIC BEACH
l,.
800 SEMINOLE ROAD
u ,,.% , x ATLANTIC BEACH, FL 32233
" d ` ' r INSPECTION PHONE LINE 247 -5814
Application Number 12- 00000088 Date 1/24/12
Property Address 1767 SEMINOLE RD
Application type description PLUMBING ONLY
Property Zoning TO BE UPDATED
Application valuation . . . 0
Application desc
5 fixtures
Owner Contractor
JERPBAK, DONALD BILL FENWICK PLUMBING
1767 SEMINOLE RD 8245 BEACH BLVD
ATLANTIC BEACH FL 32233 JACKSONVILLE FL 32216
(904) 242 -0444 (904) 724 -7022
Permit PLUMBING PERMIT
Additional desc .
Permit Fee . . . 90.00 Plan Check Fee . . .00
Issue Date . . . Valuation . . . . 0
Expiration Date . 7/22/12
Other Fees STATE PLBG DCA SURCHARGE 2.00
STATE PLBG DBPR SURCHARGE 2.00
Fee summary Charged Paid Credited Due
Permit Fee Total 90.00 90.00 .00 .00
Plan Check Total .00 .00 .00 .00
Other Fee Total 4.00 4.00 .00 .00
Grand Total 94.00 94.00 .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 (904) 247 - 5826 Fax (904) 247 -5845
JOB ADDRESS: [ 0(.01 ,,,,S .) Q Q a t r Q (e_ U E PERMIT #
NEW OR REPLACEMENT INSTALLATION: Project Value $ i
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 l
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
q�
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 r
" 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 * *
** 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 `f.-� d . e lo
xp -C Phone Number 04 -2,04` `�
Plumbing Company bUJ XQ.�1 -uc= i Cam-- + `19 t b A-4--c. Office Phone '22 `(`�vu-- Fax 0 2-4 C
Co. Address: ?SD,`-�5 b U Q J'- 611 City - State R Zip 322-'
LO,Ense Holder (Print): .0 1 L 1 Ce.n. W t dr_ State Certification/Registration # CFCs) 4 0037
A.. _.prized Signature of License Holder .LIW biaL)1 Ck _
BROOKE F DOWNING
Sworn ands scribed before me this Zk day of N (�� 201
`' �, - d�w"�I
''i •' MY COMMISSION if EE143391 Si of Notary Public
` � EXPIRES November 02. 2015
1 (407) 3.0153 FbiidalloWyisrvic..com