344 5th st 2014 deck summer kitchen CITY OF ATLANTIC BEACH
SS
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
RESIDENTIAL ADDITION
e IT BArY ENSPEffEON.- 247 5811:4
efti:BV 4PM F R NEK
JOB INFORMATION:
Job ID: 14-00001399
3ob Type: RESIDENTIAL ADDITION
Description: enclose deck/summer kitchen
Estimated Value: $100,000.00
Issue Date: 9/25/2014
Expiration Date: 3/24/2015
PROPERTY ADDRESS:
Address: 344 5TH ST
RE Number: 169836-0020
PROPERTY OWNER:
Name: GREENE 111, CLARENCE &ASHLEY,
Address:
GENERAL CONTRACTOR INFORMATION:
Name: MCCUMBER HOMES INC
Address:
Phone: - -
PERMIT INFORMATION: BUILDING DEPARTMENT: PLANNING AND ZONING: PUBLIC
WORKS:
2010 FLORIDA BUILDING CODE, 2008 NATIONAI ELECTRIC CODE *REPORT ANY
UNFORSEEN STRUCTURAL DAMAGE TO THE BUILDING DEPARTMENT
IMMEDIATELY. WINDOW AND DOOR INSPECTION: *INSTALLATION
INSTUCTIONS REQUIRED *ALL STICKERS ARE TO REMAIN ON THE WINDOWS
*PROVIDE ACCESS TO ALL WINDOWS TO INSPECT FASTENERS
PER DR
FEES:
BUILDING PERMIT FEE $480.00
STATE DCA SURCHARGE $7.20
PLAN CHECK FEES $240.00
STATE DBPR SURCHARGE $7.20
�tgV,P�W�D ONLY IN ACCORDANCVY
,V&L CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
F"IL COpy
800 Seminole Road, Atlantic Beach, FL 32233
Office (904) 247-5826 Fax (904) 24',-5845
Job Address: 344 5 1h Street, Atlantic Beach, Florida 32233 Permit Number:
/
Legal Description 5-69 16-2S-29E .17 Atlantic Beach Lot 17 BLK 6 Parcel# 169836-0020
Floor Area of Sq.Ft. Sq Ft
Valuation of Work Proposed Work heated/cooled 208 non-heated/cooled 0
Class of Work(circle one): New Addition Alteration Repair Move Demolition pool/sy window/door
Use of existing/proposed structure(s) circle one): Commercial Residential
If an existing structure,is a fire spriler system installed? (Circle one):---Ve_s__I�o N/A
Florida Product Approval# SEE ATTACHED PRODUCT APPROVAL SHEET
For multiple products use product approval form
Describe in detail the tvne of work to be performed: Enclose second floor deck to become AC living space, CA�W aft.
screened spa and swimmmp-Dool;�va wood decking, covered olitclog
cabana with out-si-d-e-ki—tchen/grill
Property Owner Information:
Name: Clarence Greene Address: 344 51 Street,
city Atlantic Beach State Florida Zip___322 3 3 Phone (904)703-3967
E-Mail or Fax#(Optional)
Contractor Information:
Company Name: McCumber Homes of Pont Vedra, Inc.Qualifying Agent: Gga McCumber
Address: 202-353 Tuscan Wgy Citv Saint Augustine State Florida Zip 32092
Office P�on 904-823-1900 Job Site/Contact Number 904-669-2931 Fax# 904-823-9186
State Certification/Registration# CGC1512380
Architect Name&Phone# Vermey Architect 904-246-1150 Peter Coalson 904-759-2556
Engineer's Name&Phone# NA
Fee Simple Title Holder Name and Address Clarence Greene 344 5'Street,Atlantic-1each. Florida 32233
Bonding Company Name and Address None
Mortgage Lender Name and Address
A 1, a, he eb made, bain a ermit to do the work and installations as indicat no work or installation has commenced prior to the
Y d ih , , rk p,b e 0 ed to_Z,t�stan a ds a, rs A,ructioninthisjurisdiction. This permit becomes null
io r 00
pp nce a per it an a a' i' rm 4r 0 k i s. f six months at any time after
-ns, Wells, Powls,01),
six t or co struct or 0
6 n 'on dr Jonedfor a period o
,SCr f
'n wo ,w e p mo d or El a,7c, ;,4g,Sig rnaces, Boilers, Heaiers,
ss-a 0 in
d thin
d"'d 0 k is not c om mence w
d 1 derstand t at Separate per its in. t b e e
f
..,k is 0 "'Ce
T"ks a At,Con onen,etc.
WARNING TO OWNER: YOUR FAILURE TO REC -)RD A NOTICE OF
COMMENCEMENT MAY RESULT IN YOUR PAYING T'0.4CE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FF-.- �,,NCING, CONSULT WITH
YOUR LENDER OR AN ATTORNEY BEFORE RECORi"ING YOUR NOTICE OF
COMMENCEMENT.
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions oflaws and ordinances gov this
j
work will be co�nplied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or=the
provisions ofany otherfedera" 'I Jaw regulating construction or the peifio�mance ofconstruction.
Signature of Owner Signature of Contractor
Print Name L ::L Print Name 677-,K�
.............................................................j;j................................................
Sworn to and subscribed before me Sworn to and su', e e re me
this,-& Day of _f, ,ttt<A� 20 Iq thisagftm 01- 20
Kimberly J.Ferris
Notary Pugbi�i`cj Imutal y .ubl'e Notai5T`Puic� V, itary ruU11%,
State of Florida ,te ot Florida
My Commission Expires 12105/2016 my Comm. )n Expires i ZW&Q*1.26.10
commission No. EE 850671 .t4n.EE85W7i
Doc # 2014191991 , OR BK 16890 Page 591 , Number Pages: 1, Recorded 08/25/2014
at 03:35 PM, Ronnie Fussell CLERK CIRCUIT COURT DUVAL COUNTY RECORDING $10 .00
F COPY
IL E
NOWE OYCqMWNCEMIENT
Tax Folio No. 169836-0020
4
bom; t-May Concern:
TheAndpit�ed heyoy informs,you.that improvements will.be made to certain real property,and in accotdince with Secdon 713 of
i stated in this NOTICE OF COMMENCEMENT.
Wes, ng information s
f' rty being improved: 5-69 I&2S—29E.17 ATLANTIC BEACH LOT 17 BLK 6
Ddsm' p Ph o p�bpe
AddrosoVf property being improved: STREET,ATLANTIC BEACH.FLORIDA 32233
ts li IT
,oialooscription of improvement 0 M A D ION,DEC _SC E_ED LA SPA,CABAk[A KITCUN..
�X Ifi N POO ND
Address nANTIQ BEACH,�LLA 32D
4, hw�
wh
�'..Clqrence Greene i 344 51b STREET,A
M,
sintimit in site of the improvement: FEE SIMPLE
tjohdIder.(if other than owner):
MCafflBER HM(ES OF P_QNTE VEDRA,M.
Nil
A --Addre.ss: 202-3�3 T_!J8QM WAXi SAINT AUOUSTINE.FLORIDA 32092
-Tol
Fax No: 904423-9186
#ny
Amount of Bond
Addres$':
Telephone No:, Fax No:
Nawo..#nd addr�ssqfaoy person making a loan for the construction of the improvements
N
a.me",
X Fax No:
N upon whom notices or other documefib may be
State of Florida,other than himself,designated by owner
Pfi
-To ephone No:
Fax No:
A In�Wiffiti&-Jo:himself, 'owner designates the. following person to receive a.copy of the Lienor.'s Notice as provided in Section
mi.66(2,
)(-b)j.fIoridaStatucs* (Fill at Owner'�optlqn
Address:
To ophone No:
Fax No:
Whi cute*. ofice a different date is
f N, - of-Contmencement(the expiration date is one(1)year from the date of recording unless
TFUS X OWNER
*OR$.tgCORDER1S USE ONLY
Date:
Sipecdl;�
day Of 6un
lit Before me...,
Of Florid, natty appeared.
J.Ferr s has peno
e,Sta.t6 6 F14 j of Duval.
P! NOWN Public Notari,��It4 it Larg f
A S df Fjorlda c it
My ommis.sibn expire
2/05/2016 Personally Known* 7
or
PALAU
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n1alon DOW"1
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860671 Produced Id tification:
M
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FORMS Flu- COPY
FLORIDA BUILDING CODE,ENERGY CONSERVATION
FORM 402-2010 Residential Building Thermal Envelope Approach ALL CLIMATE ZONES
Scope:Compliance with Section 402 of the Florida Building Code,Energy Conservation,shall be demonstrated by the use of Form 402 for single-and multiple-family residences of three
stories or less in height,additions to existing residential buildings,renovations to existing residential buildi s,new heating,coding,and water.heating systems in existing buildings,as
applicable.To comply,a building must meet or exceed all of the energy efficiency requirements on Table 40 gand all%plicable mandatory requirements summarized in Ta le 402B of this
form.If a building does not comply with this method or Alternate Form 402,it may still comply under Section 405 of t e Florida Building Code,Energy Conservation.
PROJECT NAME: BUILDER: AV-
AND ADDRESS: PERMITTING
OFFICE:
OWNER: /
PERMITNO.: JURISDICTION NO.:
General Instructions
1.New construction which incorporates any of the following features cannot comply using this method:glass areas in excess of 20 peicent of conditioned floor area,electric resistance
heat and air handlers located in attics. Additions!�600 sq.ft.,renovations and equipment changeourts may comply by this method with exceptions given.
2.Fill in all the applicable spaces of the'To Be Installed"column on Table 402A with the information requested.All"To Be Installed"values must be equal to or more efficient than the
required levels.
3.Complete page 1 based on the'To Be Installed"column information.
4.Read the requirements of Table 402B and check each box to indicate your intent to comply with all applicable items.
5.Read,sign and date the"Prepared By"certification statement at the bottom of page 1.The owner or owners agent must also sign and date the form.
Please Print CK
1. New construction,addition,or existing building 1. A'�6()I 710AI
2. Single-family detached or multiple-family attached 2. -576VI;1,15 r0AI-1/6'/
3. If multiple-family-No.of units covered by this submission 3. I<///-)-
4. Is this a worst case?(yes/no) 4. A//A�
5. Conditioned floor area(sq.ft.) 5.
6. Glass type and area:
a.U-factor Ga.
b.SHGC 6b.
c.Glass area 6c. C� sq.fL
7. Percentage of glass to floor area 7.
B. Floor type,area or perimeter,and insulation:
a,Slab-on-grade(R-value) 8a.R= --U IIn.fL -
b.Wood,raised(R-value) 8b.R= /59 5-sq.ft. -
c.Wood,common(R-value) 8c.R= sq.tL -
d.Concrete,raised(R-value) 8d.R=_ -sq.ft.
c.Concrete,common(R-value) 8e.R= ___------sq.ft.
9. Wall type,area and Insulation:
a.Exterior: 1. Masonry(Insulation R-valuc) ga-1. R sq.ft.
2. Wood frame(Insulation R-vallue) 9a-2. R= el��sq-ft-
b-Adjacent: 1. Masonry(Insulation R-value) 9b-1. R= _sq.ft.
2- Wood frame(Insulation R-value) 9b-2. R=- -sq.Ift,
10. Ceiling type,area and Insulation:
a.Under attic(Insulation R-value) I Oa.R
- sq.ft.
b.Single assembly(Insulation R-value) 10b.R=- sq.ft.
11. Air distribution system,Duct insulation,location,Qn
a-Duct location,insulation 11a. R= OP
b.ARU location 11 b. A/ kl-
c.Qn,Test report attached(<0.03;yes/no) 11c.Test report attached? Yes No
12. Cooling system: 12a.Type:
a.Type 12b.SEER/EER:
b.Efficiency
13. Heating system: 13 a.Ty p e:
-1� 13b.HSPFICOPIAFUE-*
a. ype
b.Efficiency
14. HVAC sizing calculation:attached 14. Yes No
15. Hot water system: 15a.Type,
a-Type 15b.EF:
b.Efficiency
I hereby certify that the plans ifications caverpAby the calculation are in compliance with the Florida Review of plans and specifications covered by this calculation indicates compliance with the Florida
Energy Code. Energy Code.Before construction is completed,this building will be inspected for compliance in
accordance with Section 553.908,F.S.
A'
PREPARED BY--
DATE:
7 CODE OFFICIAL:-
hereby that th* it is' compianc. Florida Energy Code:
OVMER AGENT DATE: DAR: r
2010 FLORIDA BUILDING CODE-ENERGY CONSERVATION
C.4
FILE COPY ; ,.
Existing
6' Fence
Swale
New Cabana Existing 6' Fence
Existing Slope U*)
6' Fence Perimeter
to Existing
Swales
New Wo od Deck
Second Fl( or Remove Small
Addition Paver Patio
Coverage 44.7%
Lot 7500
Existing Residence
L.Fj
Maintain Footprint 2757
Paver x 50% 350
Silt Fence Ln New 243
During pool
Construction
Concrete Stem wall 76.50
Cabana Roof Area 166.75
Grade remains
unchanged Total New coverage 243.25 SQ. Ft.
C:
4�
2 6" Cover
Material Parking
Storage
Silt Fence
5th Street
SITE MANAGEMENT PLAN GREEN ADDITION
__T
11FILE OPY !� *
FIFTH STR'
(40' R/W)
Cf)
tz�
Cf
LOT 39
U)
zAa-BUILT GFNFRAL NOTES,
I. CER71FICATE OF AUTHORIZAT10N LB #6991.
2. ELEVATIONS SHOWN HEREON ARE BASED ON ASSUMED DATUM.
3. ONLY THOSE EASEMENTS, RESTRICTIONS, AND RIGHT OF WAYS
KNOWN TO THE SURVEYOR ARE SHOWN HEREON; NO ABSTRACT WAS
SUPPLIED TO OR REVIEWED By SURVEYOR.
4. NO UNDERGROUND FOUNDATIONS OR UTILITIES & NO
IMPROVEMENTS, OTHER THAN THOSE SHOWN WERE LOCATED UNDER
THE SCOPE OF THIS AS-BUILT SURVEY.
5. ADDITIONS. DELETIONS AND/OR ANY WRITTEN INFORMAT10N ADDED
TO THIS MAP ANDIR REPORT IS PROHIBITED AND IS NOT
AUTHORIZED BY THE SIGNING SURVEYOR. F
6. THIS MAP IS INTENDED TO BE MEWED AT A SCALE OF
SMALLER.
7. COPYRIGHT 2010 13ARTRAM TRAIL SURVEYNG. INC. LOT 19
E3, THIS AS-BUILT SURVEY IS BEING PROVIDED SOLELY FOR THE USE (IMPROVED)
OF THE CURRENT PARTIES AND NO CERTIFICATION HAS BEEN
CREATED, EXPRESS OR IMPLIED, TO COPY THIS SURVEY. ANY COPIES
OF THIS SURVEY THAT ARE USED IN ANY SUBSEQUENT TRANSACTIONS
SHALL BE NULL AND VOID IF THEY DO NOT BEAR THE EMBOSSED
RAISED SEAL OF THE SIGNING SURVEYOR. THE USE OF SUCH
DOCUMENTS RELEASES THE SIGNING SURVEYOR OF ANY FURTHER
CLAIMS OF LIABILITY OF ANY SUBSEQUENT TRANSACTIONS.
9. DIMENSIONS ARE IN FEET AND DECIMAL PARTS THEREOF.
10. THIS AS-BUILT SURVEY IS ONLY FOR THE LANDS AS DESCRIBED,
IT IS NOT A CER11FICATE OF TITLE, ZONING, EASEMENTS OR FREEDOM
OF ENCUMBRANCES.
11. THIS AS-BUILT SURVEY WAS NOT INTENDED TO DELI�
DEFINE ANY WETLANDS, ENVIRONMENTALLY SENSITIVE ARE
HABITATS OR JURISDICTIONAL LINES OF ANY FEDERAL, STATE,
REGIONAL OR LOCAL AGENCY, BOARD, AND COMMISSION OR OTHER
ENTITY AND ANY LIABILITY RESULTING THEREFROM IS NOT THE
RESPONSIBILITY OF THE UNDERSIGNED.
12. UNLESS A COMPARISON IS MADE, MEASURED BEARINGS AND
DISTANCES ARE IDENTICAL WITH PLAT VALUES.
13. THIS AS-BUILT SURVEY IS BASED ON INFORMATION AS PRDVIDED
BY THE CLIENT.
14. THIS IS NOT A BOUNDARY SURVEY.
15. THE PURPOSE OF THIS AS-BUILT SURVEY IS TO SHOW ON-SITE
DRAINAGE ONLY, L
LOT 2
GRAPHIC SCALE
20 0 tc 20 40 so
_P_R_E_PA..R_ED FoR: IN FEET
I inch = 20 ft.
REVISION DATE By CK'D FB/PG DESCRIPTION DRAWN BY: CD
CHECKED BY: ASID BARTP" TKUL
F.I.R.M. FLOOD ZONE X LAND SURVEYORS - PLANNERS
1501 COUNTY I
ELEVATION: N/A FLA GREEN COVE
0 01 D 4/17/89 PHONE (5
632/06- FAX (9C
FB/PG: & EW LF
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Green Addition Connectors Product Approval
F2 Rafter to Plate H2.SAZ FIL 10456
F3 Stud to Band MTS 20 FL 10852 FL13872
F4 Band to Stud MTS 20 FL 108S2 FL13872
F1 Shear wall to Beam HTT4 FL104S6 FL11496
F1 Shear wall to slab HTT4 FL10456/ FL11496
F5 Floor Joist to beam LUS 210 FL10655
F6 Post Base ABA66Z FL 10849
F7 Post Cap EPC 66 FL 10860
F8 Exposed Rafter to Beam H25ASS FL10456
F9 Ridge to Joist LTS 12 FL 10456/ F113872
F10 2-2x12 beam to LVL LUS210-2 FL10655
F11 LVL Beam to LVL LGU3.63-SDS FL10531/FI11468
F12 2-2x12 Beam to wall HUC412 FL10531/FL10655
City of Atlantic Beach
Building Department APPLICATION NUMBER
800 Seminole Road CEIV]ED (To be a�ssigneddlbb the Building Department.)
Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 - Fax(904) 7-584AUG 2 7 2014
E-mail: building-dept@coab.us FD�ate routed: 24
Cityweb-site: http://www.coab.us
APPLICATION REVIEW AND TRACi JNG FORM
Property Address: ... '57W J-T D nt__review required -Ve—s -4-o-
Buildin
D
Bu ild in
t r'
nnine =Zon�&7��
Applicant: il
di istrator
s
Project: 4�n d1046 ublic
U U s
diiiies
tl-
Public Sa
f,7-fe t y
'Ic
Fire Services
Review fee $ Dept Signature
Other Agency Review or Permit Required Review or Receip Date
of Permit Verified I
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. []Approved. [�eeniecl.
(Circle one.) Comments: 477WC 44 6-0
BUILDING
PLANNING &ZONING
Reviewed�by: Date:
TREE ADMIN. 'is
Second Review: mA/pproved as revised. enied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES /4-'-7--avc t4
PUBLIC SAFETY Reviewed by:
_ _�6 - �Date.-:�?//
FIRE SERVICES Third Review: DApproved as revised. Denieul.
Comments:
Reviewed by: Date:
?evised MUM
City of Atlantic Bet <-h
APPLICATION NUMBER
Building Departmt, i (To be assigned by the Building Depart
800 Seminole Road LMent.)
Atlantic Beach, Florida�5233-5445
Phone(904)247-5826 - Fax(904)247-5845
E-mail: building-dept@coab.us �1 -
Cityweb-site: http://www.coab.us Date routed: 2
APPLICATION REVIEW AND TRACKING FORM
Proper�y Address:
J-7 De ent review required Y
Buildin
Applicant: nnin
Q
B
e
u'Idin
an
ist review Rreqred
Project: b20'1,6-6e- e dr,;7iinistrator
F� J te ublic rks
S
h.�Al - Public Sat-ety
F ir S "Ic
#ire Serv.i--es
Review fee Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified By
Florida Dept.of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Manacement District
Army Corps of Engineers
Division of Hotels and Rest nts
Division of Alcoholic Beverag, ,and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review. []Approved. e n i e o.
(Circle one.) Comments: 5?ee
BUILDING
PLANNING &ZONING
Reviewed Date:
TREE ADMIN.
Second Review:)dApproved as revised. nDenied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed b Date:
FIRE SERVICES Third Review: []Approved as revised. []Denie(,i.
Comments:
Reviewed by:_ Date:--
Revised 05/14/09
City of Atlantic Beach
APP
Building Department ir LICATION NUMBER
.'1 800 Seminole Road (To be assigned bD the Building Department.)
Atlantic Beach, Florida 32233-5445
V Af 9
Phone(904)247-5826 - Fax(904)247-5845
jj u)�-` E-mail: building-dept@coab.us
Date ro�uted:
City web-site: http://www.coab.us
APPLICATION REVIEW AND TRACKING FORM
Property Address: _3y� 6-7w J-T De ent review require Y
Buildin
Applicant: nnin
De
n
t review required
drnin Istrato%
i r
Project: "O�n el'66 e- ublic rl
Utilities
All hS Public Safety
gFireServices
Review fee $_ Dept Signature
Other Agency Review or Permit Required Review or Receipt Date
— of Permit Verified By
Florida Dept. of Environmental Protection
Florida Dept. of Transportation
St.Johns River Water Management 1571s—tdct
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATION STATUS
Reviewing Department First Review- M/Approved. F]Deniea.
(Circle one
qE�9.) Comments: 6va,&I V,S -ry'r P'e S-V (I-Ha 5, 'fo r zaayk'N15
PLANNING &ZONING Reviewed by: 191 — -Date:V_2-�J
TREE ADMIN. Second Review: []Approved as revised. RDVnied.
PUBLIC WORKS Comments:
PUBLIC UTILITIES
PUBLIC SAFETY Reviewed by: Date:
FIRE SERVICES Third Review: DApproved as revised. FIDenied.
Comments:
Reviewed by: Date:
Revised 051114/09
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD
ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
ELECTRICAL PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 14-ELEC-394
Job Type: ELECTRIC ONLY
Description: WIRE FOR ADDITION, 18 OUTLETS
Estimated Value:
Issue Date: 12/4/2014
Expiration Date: 6/2/2015
PROPERTY ADDRESS:
Address: 344 5TH ST
RE Number: 169836-0020
PROPERTY OWNER:
Name: GREENE 111, CLARENCE 8, ASHLEY,
Address: 344 5TH ST
GENERAL CONTRACTOR INFORMATION:
Name: ALLSTATE ELECTRICAL CTR INC.
Address: P 0 BOX 550617 QA JAMES L. WILLIAMS
Phone:
FEES:
State Elec DBPR Surcharge $2.00
State Elec DCA Surcharge $2.00
Electrical Repairs $35.00
Switch Outlets $8.40
Lighting Outlets, Including Fixtures $2.40
Trade Permit Base Fee $55.00
Total Payments: $0.00
PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
PLUMBING PERMIT APPLICATION
CITY OF ATLANTIC BEACH
800 Seminole Rd Atlantic Beach, FL 32233
Ph(904) 247-5826 Fax (904) 247-5845
JOB ADDRESS: PERMIT# I q- 13��
NEW OR REPLACEMENT INSTALLATION: Project Value$
TYPE OF FiXTURE QTY TYPE OF FiXTURE QTY
Bathtub Septic Tank&Pit
Clothes Washer Shower
Dishwasher ShowerPan
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:
Ei Sewer Replacement E:i Back Flow Preventer E:i Grease Interceptor(Trap) gallons(Requires 3 sets of plans)
F-i Lawn Sprinkler System-Number of Heads E Well ction.**
SJR WD Well Completion Form. Completed—form to be submitted to the—Building Department for final inspe
El Other IL- L4.;p A�L' --t %C jot QL
V
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 Phone Number
Plumbing Company —Office Phone.W�-�S`ff _Fax�PJ 3 7 SD
City_�y�,
Co. Address: D;;13a do v-,2 oy-Je- Q�>rv— 5)\28 State F1_ Zip 1221(-
License Holder (Print): G-evoc, (L 60c/' -,$tate�\Certiltfic;ation/Registration# C�C,
UA b'_'�
Notarized Signature of License Holder
Sworn and subscribed before me this—day of 20
Signature of Notary Public