888 SEMINOLE RD PLRS20-0152 NLKszo - e1) sz
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Plumbing Permit Application **ALL INFORMATION
� HIGHLIGHTED IN
='\ City of Atlantic Beach Building Department GRAY IS REQUIRED.
r 800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904)(9247-5826 Email: Building-Dept@coab.us PERMIT#: C-) (..10-0004,
ADDRESS: ($X JF,M,T2 OC 2c 0 D . PROJECT VALUE $ /t ol�(> (.70
❑NEW OR REPLACEMENT INSTALLATION and/or ❑RE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank& Pit
Clothes Washer Shower
Dishwasher Shower Pan
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 Water Heater
Other Fixtures Water Treating System
❑MISCELLANEOUS
❑ Sewer Replacement
❑ Back Flow Preventer
Li 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.
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Owner Name: 9bta�.t? �l�►1� C=T�- Phone Number: i G���Z
Plumbing Company: jiac ,11rt-t.. Pc13C •tz Office Phone: `171 5z-46G Fax
Co. Address: 5 OLDirrvNu..P.t NA ep _ City: e1 a- 1 Stater Zip: 30-2X,
License Holder: t Q.NJ ( ....AC -1 State Certification/Registration# Cda_)Li Mb
Notarized Signature of License Holder 14
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The fore of i trument s acknowledged befe this da • 20 the State of g g I lb �� 2 Florida,
County ofv\f4-
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Signature of Notary Public 3 L \
• ,s*wY � TONIGINDLESPERGER [ ] Personally Known OR [ ] P oduced Identification
:`(•,., '1.,,-",, MY COMMISSION#GG 353178 `�
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Type of Identification:
i ` �` EXPIRES:Cctobec ,2023 v
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Bonded Thru Notary Public Underwiters Updated 10/17/18