49 DUDLEY ST PLRS20-0161 ?LRSzc - 0IG (
PlumbingPermit Application **ALL INFORMATION
pp HIGHLIGHTED IN
J r "� City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: '/e1_S ZD v/ 7Z-
JOB ADDRESS: `�/9 Drtidier S-. PROJECT VALUE $ d�
[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
Hose Bibs z Urinal
Kitchen Sink / Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory 1/ Water Heater /
Other Fixtures / ) Water Treating System
❑MISCELLANEOUS ,t'
❑Sewer Replacement
❑Back Flow Preventer
❑Lawn Sprinkler System (number of sprinkler heads)
D3rease Interceptor(Trap) gallons(Requires 3 sets of plans)
❑Well **SIRWD 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:/42mc/rs LUcKy Phone Number:
Plumbing Company: ,,shine 614 4. J/;A L:5 Office Phone:9,9V.Z/.2-/o// Z. Fax
Co.Address: 7/P /h,,7ef 1/' City: -..Tar State: 71-e Zip: 3Z 2bZ
License Holder: /7r`ige/? e7r7{/r- State Certification/Registration#({/' /V261 -7
Notarized Signature of License Holder 11!I t '"
The foregoing instrument was acknowledged before me this -2- day of 1\Jov'-m t,-(-‘, 20)-4" in the State of Florida,
County of -.1)1,,\;70—(9
�4�avrue�c DAVINARDICKERsOG Signature of Notary Public
Commission#GG 148032
Expires October 22,202 179-Personally Known OR [ ] Produced Identification
'',e0F Fp BondaeThru Budysl Notal Type of Identification:
Updated 10/17/18