76 OCEAN BLVD PLRS20-0139 )LKSZO CC13
Plumbing Permit Application **ALL INFORMATION
b �� HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
/% 800 Seminole Rd, Atlantic Beach, FL 32233 c'1
Phone: (904) 247-5826 Em 'I: Building-Dept@coab.us PERMIT Th1 10 -0015-7
JOB ADDRESS: 76; PROJECT VALUE $ srl >L
VNEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank& Pit
Clothes Washer I Shower I
Dishwasher 1 Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink 11 Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory I Water Heater I
Other Fixtures Water Treating System �—
❑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: LI r\ Phone Number:
Plumbing Company: 540,160 P/✓mil M' Office Phone: ?Oy ? 7 ( Oa1 Fax
Co. Address: SLI 57 141 clam Rd City: .5NCt State: FL Zip: 3 220'–i
License Holder:.)-L'4Cry B(4 State Certification/Registration # CPC./`/Z8$4G
Notarized Signature of License Holder
The forego cialstrument was acknowledged efore me thiV 3 day oi` -xp , 202oin the State of Florida,
County of V�
Signature of Notary Pubii ---„
'"Yy TCNIGINDLESPERGER Personally Known OR [ ] Produced Identification
MY COMMISSION#GG 353178
.0"7 EXPIRES:October 6,2023 Type of Identification:
'..f cr i�?•• Bonded Thru Notary Public Underwriters
Updated 10/17/18