380 12th St PLRS19-0092 plbg permit PLUMBING RESIDENTIAL PERMIT PERMIT NUMBER
PLRS19-0092
V� CITY OF ATLANTIC BEACH ISSUED: 5/13/2019
800 SEMINOLE ROAD
r�;ss�%' EXPIRES: 11/9/2019
ATLANTIC BEACH. FL 32233
MUST CALL INSPECTION PHONE LINE (904) 247-5814 BY 4 PM FOR NEXT DAY INSPECTION.
ALL • 'K MUST CONFORM TO THE CURRENT 6TH EDITION1 OF • ' D+ BUILDING
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE OF ORDINANCES .
ALL CONDITIONS OF PERMIT APPLY, PLEASE READ CAREFULLY.
NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
that may be found in the public records of this county, and there may be additional permits required from other
governmental entities such as water management districts, state agencies, or federal agencies.
JOB ADDRESS: PERMIT TYPE: DESCRIPTION: VALUE OF WORK:
380 12TH ST PLUMBING RESIDENTIAL INSTALL 37 FIXTURES NEW $25000.00
SINGLE FAMILY HOME
TYPE OF +
• • GROUP:
171930 0000 SELVA MARINA UNIT 01
COMPANY: ADDRESS: STATE:
HERZER PLUMBING 3453 E RED OAK CIR ORANGE PARK FL 32073
SERVICE
• ADDRESS: '
PETER & AMY POLLAK 380 12TH ST ATLANTIC BEACH FL 32233-5514
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT
IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN
ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
LIST OF • . •
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 37 $259.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $4.71
STATE DCA SURCHARGE 455-0000-208-0600 0 $3.14
TOTAL:$321.85
Issued Date: 5/13/2019 1 of 2
U
Plumbing Permit Application **ALL INFORMATIONHIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY I5 REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Build ing-Dept@coab.Lis PERMIT#: PC—eS ict--OOct
JOB ADDRESS: 380 12th Street PROJECT VALUE $25,000.00
ZIEW OR REPLACEMENT INSTALLATION and/or [IRE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub 3 Septic Tank & Pit
Clothes Washer 2 Shower 5
Dishwasher 1 Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet 6
Hose Bibs 5 Urinal
Kitchen Sink 2 Vacuum Breakers
Laundry Tray 1 Water Connected Appliances 1
Lavatory 8 Water Heater 2
Other Fixtures Water Treating System 1
E MISCELLANEOUS
❑Sewer Replacement
[]Back Flow Preventer
❑Lawn Sprinkler System (number of sprinkler heads)
Ehrease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑Well **SIRWD 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.
Owner Name:Peter&Amy Pollak Phone Number:
Plumbing Company: Herzers Plumbing Service Office Phone: 264-6171 Fax
Co. Address: P.O. Box 422 City: Orange Park State: FL Zip: 32067
License Holder: Glenn Buchman State Certification/Registration # CFC033873
Notarized Signature of License Holder OC/✓�Iln `>C� �tN�D�N�
The foregoingCs'ru ent was acknowledged before me this ) day of Q t' , 20 in the State of Florida,
County of
Notary Puotic=State
Signature of Notary Publics/C�� r I
�"'i�w my EPersonally Known OR [ ] Produced Identification
Type of Identification:
Updated 10/17/18
J3 ri�1�/n
d Register
• • • • • ReceiptNumber
City of Atlantic Beach R9027
DESCRIPTION ACC• CITY PAID
PermitTRAK $321.85
PLRS19-0092 Address: 380 12TH ST APN: 171930 0000 $321.85
PLUMBING $314.00
PLUMBING BASE FEE 455-0000-322-1000 0 $55.00
PLUMBING FIXTURES 455-0000-322-1000 37 $259.00
STATE SURCHARGES $7.85
STATE DBPR SURCHARGE 455-0000-208-0700 0 $4.71
STATE DCA SURCHARGE 455-0000-208-0600 0 $3.14
TOTAL FEES PAID BY RECEIPT: R9027 $321.85
Date Paid: Monday, May 13, 2019
Paid By: HERZER PLUMBING SERVICE
Cashier: CT
Pay Method: CREDIT CARD 013748
Printed: Monday, May 13,2019 8:48 AM 1 of 1
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