635 SELVA LAKES CIR PLRS21-0106 PlumbingPermit Application **ALL INFORMATION
/� MnM HIGHLIGHTED IN
/ '' City of Atlantic Beach Building Department GRAY IS REQUIRED.
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800 Seminole Rd, Atlantic Beach, FL 32233 P R Z ( - Oi O(67
Phone: (904) F247-5826 Email: Building-Dept@coab.us PERMIT#:-(025.12510d9
17 eACk 3Z23?
JOB ADDRESS: h 3 S S s _LJ A LA AC i I > ' PRO ECT VALUE$ 4,2 50 -
❑NEW OR REPLACEMENT INSTALLATION and/or RE—PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub I Septic Tank& Pit
Clothes Washer A Shower
Dishwasher / Shower Pan
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet 2.
Hose Bibs 2- Urinal
Kitchen Sink Vacuum Breakers 2--
Laundry Tray Water Connected Appliances
Lavatory 2 Water Heater /
Other Fixtures 7---- - - ater Treating System
❑MISCELLANEOUS
❑ Sewer Replacement
❑ Back Flow Preventer
❑ Lawn Sprinkler System (number of sprinkler he.•s
❑ 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. >' 9
Owner Name: �l Mi L A L.,J A Phone Number: (( 964 3 3 . SS(y
Plumbing Company: L kf� I u./'I Dai N6 cop ffice Phone: C YOh/a93'SsC4ax
Co. Address:.43811 kA wil-S L.LF OR / L J City: .(A,,, State: k- Zip: 3Z &t
License Holder: .'P F R lM f\ +' AL,/A State Certification/Registration # /l F//7 ' 7-6•_//
Notarized Signature of License Holder t-1 rr "-C" -- (41. 4-
The forego) g i rument wa acknowledged before me this I day_ of L._- , 20Z ( in the State of Florida,
County of L V c✓� •
Signature of Notary Publi ,' ` ,
[ ] Personally Known OR [ Produced Identification
ppl 1;it. TONI GINDLESPERGER Type of Identification: 6_ C
•. ac., :, MY COMMISSION#GG 353178 Updated 10/17/18
,: P EXPIRES:October 6,2023
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'' ,,F F�� Bonded Thru Notary Public Underwriters