775 PLAZA - PLRS20-0114 Plumbing Permit Application **ALL INFORMATION
f HIGHLIGHTED IN
• 1 City of Atlantic Beach Building Department `` GRAY IS REQUIRED.
;1
800 Seminole Rd, Atlantic Beach, FL 32233 PL RS Z0-0114-
ss:t> Phone: (904) 247-5826 Email: Buildinv-De_pt@coab.us PERMIT#: RE32-CJ-0tc�
JOB ADDRESS: —1t 6 Z PROJECT VALUE $ q qo
IEW OR REPLACEMENT INSTALLATION andjor ERE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer Shower f
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry TrayWater Connected Appliances
Lavatory a Water Heater
Other Fixtures Water Treating System
OVIISCELLANEOUS
DSewer Replacement
Back Flow Preventer
D Lawn Sprinkler System (number of sprinkler heads)
❑Grease interceptor (Trap) gallons (Requires 3 sets of plans)
ID Well **SJRWD Well Completion Form. Completed fora to be submitted to the Building Department for final inspection. **
QOther __ a_..
Permit becomes void if work does riot 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. —7
Owner Name: �raC VJ ��I �"l\ ex-
Number: ( — `�"` I
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Piurribing Company: A-r)nt \\ &1. YtL)kXY'j2I fl Office Phone: �I� o � Fax cj1� J3LS
Co. Address: PD. j?yoX f '� �_.� City: 1 ��! I (.tAtate: fL Zip: -J "t-'D__
License Holder: _ .ILg1ar f-.L_ }�O I State Certification/*-gid :pion #
Notarized Signature of LicenseHolder
_�. _ •The foregoing instrument was acknowledged before me this day of , 20 , in the State of Florida,
County of
oi\CLA P L U wA
Signature of Notary Public _ .
[ ] Personally Known OR [ ] Produced Identification
Type of Identification:
Updated 10/17/18