380 SEMINOLE RD PLRS21-0012 Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
` 800 Seminole Rd, Atlantic Beach, FL 32233 PLR5Z -UC) t a
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT# Sfl
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JOB ADDRESS: 38D S trust(' s
ntrLtc2at,t (�1?� ICL, '?>> � PROJECT VALUE $ t °C)
✓❑VEW OR REPLACEMENT INSTALLATION and/or ORE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub / Septic Tank & Pit
Clothes Washer —4— Shower
Dishwasher Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet
Hose Bibs Urinal
Kitchen Sink / Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory a Water Heater
Other Fixtures Water Treating System
❑MISCELLANEOUS
❑Sewer Replacement i
❑Back Flow Preventer
❑Lawn Sprinkler System (number of sprinkler ads)
❑Grease 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: 41N' NI'l'5l9n Phone Number: \IOC (a—,Ga-)fi
Plumbing Company: I Oc \ &O hht Office Phone: q04-a4i-16tg Fax
Co. Address: () V\(JU3pri\\ aft City: Wziali\VII e032aon State:CJS.- Zip: 3')-)
License Holder: _ . , _ _ Stat ertification/Registration # CFL Ik4a SCjbq
Notarized Signature of License Holder I /
The foregoi strument was acknowledged before this ZCJday • �>L -!N 20 Z�in the State of Florida,
County of ( (
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,ignature of Notary Public � Valk
• ?t ?S TONI G!NDLESPERGER
MYCOMMISSION#GG 353178
October 6,2023 y
Personal) Known OR Produced Identification
F g 10 Bonded Thru Notary Public Underwriters ype of Identification:
Updated 10/17/18