1021 ATLANTIC BLVD UNIT 975 - PLUMBING (2) PLUMBING
PERMIT APPLICATION
CITY OF ATLANTIC BEACH
' 800 Seminole Rd Atlantic Beach, FL 32233
UN) A 9 '7 5 Ph (904) 247-5826 Fax (904) 247-5845 I 6- ( L a,e,_ as Q7
AS`S K SAL-4A yy
JOB DDES / D /f��
i�G4frC. 4/(/P PERMIT#
NEW OR REPLACEMENT INSTALLATION: Project Value $ Zd' 2
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank&Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain _L_ Slop Sink
Floor Drain I Three Compartment Sink
Floor Sink Toilet t
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray / _ Water Connected Appliances
Lavatory ___j__ Water Heater
Other Fixtures Water Treating System
RE-PIPE: "O n
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 o 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 6-614 i On"-- Phone Number 7`�`'t G,3-5
Plumbing Company
C A1"1r)v,�) //K,.,$'i bt Office Phone
Tic/ –�� Fax �—
Co. Address: /7/1 —L At eto / City v State Zip 321-- U
License Holder(Print): DL/Al GA 6-)0 0 riJ State Certification/Registration# (FL(W-Gic-4)
Notarized Signature of License Holder —� _
Sworn and subscribed before me this 3 day of E's kow y 20 I ke
1 „OR LESLIE DALE
n# (II
.`'` A Commission'n 2018 3 Signature of Notary Public -, \
j,!.r'4.7. ,,, ,5.,,,;Y.. O.,uiw4 e00465.10i9