62 Ocean PLRS21-0055 App Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
800 Seminole Rd, Atlantic Beach, FL 32233 p( IaS 21 0 O 5.S
Phone: (904) 247-5826 Email: wilding-DeptPERMIT#: 1 PI ao -0X 5
JOB ADDRESS: 6 0.1- cc ea,i A/vim✓ PROJECT VALUE $ 30o C 6247
✓j'JEW OR REPLACEMENT INSTALLATION and/or DRE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub Septic Tank & Pit
Clothes Washer _l_____ Shower I
Dishwasher __L___ Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet I
Hose Bibs Urinal
Kitchen Sink _i_ Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory / Water Heater I
Other Fixtures Water Treating System
❑VIISCELLANEOUS
❑Sewer Replacement
❑Back Flow Preventer
❑Lawn Sprinkler System (number of sprinkler heads)
Lrease 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: Uanc!ICL it/O/i Phone Number:
Plumbing Company: 5-te war4 Pill CoAfrixavii Office Phone:g0y PIO? y3Dc/ Fax
Co. Address: S-1157 7 H iC SOIL /w- City: 'TeX State: R- Zip: 3 2207
License Holder: 3—e-te-r\-/ eAccl State Certification/Registration #C_FC/1-{.2-?8O 6.
Notarized Signature of License Holder �. . Z ___--
7
The foregoiri nstrume was acknowledged before me this l day , 1 , AL20C- ( in the State of Florida,
County of _
L/
Signature of Notary Public -`
te.�n. vessRrd -
t Y �. 1-6N;GINDLE3PERGER I ] personally Known OR [ ] Produced Identification
"I,�! EXPIRES:Oct3ber6,2023 MY COMMISSION#GG 353178 Type of Identification:
4i '.C': F c*•' E.:Ced Thru Notary Public Underwriters
Updated 10/17/18