465 INLAND WAY PLBG21-0002 t!..AlvI,, Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 ?LEZ( -000 Z.
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: /q'--exY>3
JOB ADDRESS: ' ' � krAl PROJECT VALUE $ /`Y l Aro �"
/(/ )L-
❑NEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE5e1,41Y- QTY
Bathtub Se.p+e-Tarrk-&Pit/..?rr- r
Clothes Washer Shower 77a MC, 1
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet ( _
Hose Bibs 1 Urinal
Kitchen Sink _L_— Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory / Water Heater t
Other Fixtures Water Treating System
111 MISCELLANEOUS
\ j❑ 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: ()L ir.) jitt7431 " Phone Number:
Plumbing Company: ICelf/6'A -Tko- L c v,)(9N,Office Phone: qi,y-3�2'V7OS"' Fax
Co. Address: 36 69(.a vA- 'nI )' - 'T City: State: F— Zip: ' - ,ac—
License Holder: Mtc L: 1/A,/ !bake, State Certification/Registration # (Zt'1(P l0?ccj
Notarized Si•nature of License Holder /7 ...(--X,--
The fore:sing in rument .s acknowledged before me this 7` d i\� , 20 - �, in the State of Florida,
County of Ilk
`�"""°`" TONIINDLESP- - ature of Notary Pub ' v
-:". tRGER
�: MY COMMISSION#GG 353118
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EXPIRES:October 6,23052331
023 [ Personally Known OR [ ] Produced Identificatio
;��--,,�-=:'"" °riled Thru NotaryPublic Underwrite
""^ '' �T pe of Identification:
/ Updated 10/17/18
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