320 5th ST PLRS20-0141 PLIR zc oVt l
��1Jr Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
p, f ` City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
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Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: 720 r(. CLNR PROJECT VALUE $ /, ' `'3
El NEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer ! Shower
Dishwasher Shower Pan I
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet /
Hose Bibs Urinal
Kitchen Sink I Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory _L__ Water Heater I
Other Fixtures Water Treating System
❑MISCELLANEOUS
❑ Sewer Replacement
❑ Back Flow Preventer
❑ Lawn Sprinkler System (number of sprinkler eads)
❑ 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: 4)J/ii/7.A, #n Phone Number: `t y
Plumbing Company: f1'1 r �L'-►n Lj'i .j Office Phone:(W)4/44Vgt Fax
Co. Address: -5-3.—P-2 i'+�-a'� !`�`� City: State: /
License Holder: :f
L)h,. / '1 State Certification/Registration # F-46-> C)'$3zy
Notarized Signature of License Holder
The foreg. istrume t was acknowledged before me this i3da . -DO , 21Z(in the State of Florida,
County of v TCu
411
Signature of Notary Public' — -__.0 fiaL
i `�Y°u � TONIGINDLESPERGEr ersonally Known OR [ ] Produced Identification 4
f„'s -t,,s MY COMMISSION#GG 3533 17$
• EXPIRES:October 6,2023 T e of Identification:
ri Notary Public Unden mists
Updated 10/17/18