871 OCEAN BLVD PLRS21-0112 Plumbing Permit Application **ALL INFORMATION
r�^ HIGHLIGHTED IN
City of Atlantic Beach Building Department GRAY IS REQUIRED.
r 800 Seminole Rd, Atlantic Beach, FL 32233 PL RSZI -0 I L Z
v'" Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:,6-5-N_ 7
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JOB ADDRESS: 97/ QC(-4M'' Z,/,_„d PROJECT VALUE $ e`�DO -----
III NEW
_❑NEW OR REPLACEMENT INSTALLATION and/or ❑RE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub f Septic Tank& Pit
Clothes Washer Shower , --1--
Dishwasher Shower Pan 3
Drinking Fountain Slop Sink
Floor Drain Three Compartment Sink
Floor Sink Toilet _L_
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory I Water Heater
Other Fixtures Water Treating System
❑MISCELLANEOUS
❑ Sewer ReplacementJ,
❑ Back Flow Preventer
❑ Lawn Sprinkler System (number of sprinkler heads)
❑ Grease Interceptor (Trap) gallons (Requires 3 sets of plans)
❑ Well **SJRWD Well Completi Form.Complet formo be submitted tphre Building Department for final inspection. **
*Other ha7ia- / 1 LA/0X," ienw-,Zr-zeilr-
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: 1/.:�1 1, Phone Number: 9e24/ - r,.Z/- 5
Plumbing Company: M 14%i ,/4, Office Phone: 101 12/-(35s Fax
Co. Address: City: State: Zip:
License Holder: /f'. /7 State Ce ifi • n/Registration # L'/2 O57o1
Notarized Signature of License Holder / 4j-7C�
The forego' g i istrument wa acknowledged before me this zP_gl. o 0C , 206- (in the State of Florida,
County of _ 0 •
4 &,/
Signature of Notary Public _ Il
[ Personally Known OR [ ] Produced Identification
iiRv?yc: TONI GINDLESPERGER Type of Identification:
*: 4' - MY COMMISSION#GG 353178
: _,, :.:
;.. .o, EXPIRES:October 6,2023 Updated 10/17/18
'f.:f;°Q Bc•nded Thru No::ry Public Underwriters
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