328 W Oceanwalk PLRS19-0213 Submittal PlumbingPermit Application **ALL INFORMATION
f� �`� "� �� HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
f f 800 Seminole Rd, Atlantic Beach, FL 32233
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Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: 3 ' 67 e `-1'N c,,`,/k Q` # PROJECT VALUE $ ,.l/o 6 1'.
OINEW OR REPLACEMENT INSTALLATION and/or ORE-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 Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory Water Heater 2
Other Fixtures Water Treating System
❑MISCELLANEOUS
❑ 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: M tIN ke f Phone Number: /0V 9ft _oorI
Plumbing Company: Ot e''7 AJ (4- 1V-/'ti) ;.i Office Phone: y tib—Dal Fax 7011 -LW- 6
Co. Address: 1° °'d‘.) -- S-C 4 Y/ City: 3ti c.k So l v'//r State: FL Zip:1J 35-6 t(/
License Holder: "''7 J Nc(1-, State Certification/Registration # (FC -OST7 itY
Notarized Signature of License Holder / '1 ii-
1
The foregoil tr,umeLit was a nowledged before me this /+ day •flip• _ , 2 nin the State of Florida,
County of L) kr
Signature of Notary Public
:iv0;icik-, TONIGINDLESPERGER ] peofrsonally KnownIdentification:OR [ 1 Produced Identification 1111.; ,• ;. MY COMMISSION#GG 353178
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'.';�P" �IRES:October6r
2023 Type
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Undo/Mere] Updated 10/17/18