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1475 BEACH plumbing '6° PLUMBING PERMIT APPLICATION �t� 6k �� CITY OF ATLANTIC BEACH ■ �"e 800 Seminole Rd Atlantic Beach, FL 32233 Ph(904)247-5826 Fax(904)247-5845 1 (a— I, R. R JOB ADDRESS: 191 S (24MN kft hi l_A.tiri IC tgiA1 N , (I- PERMIT# NEW OR REPLACEMENT INSTALLATION: Project Value$ } 5°, 0. 30 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 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 ABack 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 C©2R A L Phone Number Plumbing Company Po.-° C(V1 i k tit to 6"r t O1^a Office Phone°10'1'2109'(3121 Fax Co. Address: P0. btl City Oildio ' io6+Lk State FL Zip 1.2.0�S 1�1l�V h L License Holder(Print): 30 N^ 2 61 TM &2_ State Certification/Registration# t Notarized i-nature of License Holder • ,; , , VI LHELM Before me this ;1-(\ day of ti. 'c Nosy t aaol-F _. \-759 Z Z ETV• , Commission.FF 970919 Signature of Notary Public _ i ..:-.••4A4 Conirrt,Expke u 2s 0 " Bonded through National Notary Assn