1958 Beachside Ct PLRS19-0020 VOID (1/23/19) IV) /q/62A-
� L PlumbingPermit Application **ALL INFORMATION
MM HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
f1
r 800 Seminole Rd, Atlantic Beach, FL 32233 P 2's((I
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: Iq5b pk!NAq% omw
- PROJECT VALUA
❑NEW OR REPLACEMENT INSTALLATION and/or EIRE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub I Septic Tank& Pit
Clothes Washer Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet 2
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray = Water Connected Appliances
Lavatory 2 Water Heater
Other Fixtures Water Treating System
El MISCELLANEOUS
❑ Sewer Replacement
❑ Back Flow Preventer
❑ Lawn Sprinkler System (number of sprinkler heads)
❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑ 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.
Owner Name: Phone Number:g
Plumbing Company: Office Phone: 104_3 Fax
Co. Address: , Di D 15�`r`! wv�-1 City: State: L Zip: 3m(�
License Holder: State Certification/Registration# tf� l
Notarized Signature of License Holder to VrWW�
The forego strument as acknowledged before me this y , 200 in the State of Florida,
County of (� C✓
Signature of Notary Public
[ ] Personally Known OR ] Produced Identification
Type of Identification:
QNi;,p.ir, ESPERGER
Pi Y�Ct',,;;., FF 924951 Updated 10/17/18
„a "XnIR[E 6,2019
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Issued Date: 1/22/2019