2139 Seminole Rd PLRS21-0126 10 Fixtures, Sewer Replacement PLUMBING RESIDENTIAL PERMIT PERMIT NUMBER
i 4- PLRS21-0126
-1 - CITY OF ATLANTIC BEACH ISSUED: 8/19/2021
800 SEMINOLE ROAD
=o ATLANTIC BEACH, FL 32233 EXPIRES: 2/15/2022
MUST CALL INSPECTION PHO E LI ' 14' '—'41—
4 = 8 'i 4 PM F i 1 ' s '
ALL WORK MUST CONFORM TO THE CURRENT 6TH EDITION (2017) OF THE FLO• DAB 11.
CODE, NEC, IPMC, AND CITY OF ATLANTIC BEACH CODE 0
ALL CONDITIONS OF PERM, , i PPLY, PLEASE READ CAREFO '
NOTICE: In addition to the requirements of this permit,there may be additional restrictions applicable to this property
that may be found in the public records of this county,and there may be additional permits required from other
governmental entities such as water management districts,state agencies,or federal agencies.
JOB ADDRESS: 1 PERMIT TYPE: i DESCRIPTION: VALUE OF WORK:
2139 SEMINOLE RD PLUMBING RESIDENTIAL 10 Fixtures, Sewer $20000.00
Replacement
TYPE OF j REAL ESTATE ZONING: BUILDING USE SUBDIVISION:
CONSTRUCTION: NUMBER: GROUP:
169515 0500 SECTION LAND
COMPANY: j ADDRESS: CITY: STATE: ZIP:
Clay County Master GREEN COVE
449 Arthur Moore Dr FL 32043
Plumbing LLC SPRINGS
OWNS ADDRESS: CITY: STATE: 1 ZIP:
Camille Adams 2139 SEMINOLE RD ATLANTIC BEACH FL 32233-5921
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT II\
YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT
MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE
RECORDING YOUR NOTICE OF COMMENCEMENT.
Roll off container company must be on City approved list . Container cannot be placed on City right-of-way.
DESCRIPTION ACCOUNT QUANTITY PAID AMOUNT
PLUMBING BASE FEE 455-0000-322-1000 0 $55 00
PLUMBING FIXTURES 455-0000-322-1000 0 $0.00
PLUMBING FIXTURES 455-0000-322-1000 11 $77.00
STATE DBPR SURCHARGE 455-0000-208-0700 0 $2.00
STATE DCA SURCHARGE 455-0000-208-0600 0 $2.00
Issued Date:8/19/2021 1 of 2
t ''''`��ag PLUMBING RESIDENTIAL PERMIT PERMIT NUMBER
r; PLRS21-0126
�� CITY OF ATLANTIC BEACH ISSUED: 8/19/2021
800 SEMINOLE ROAD
-``,`9131,,- ATLANTIC BEACH, FL 32233 EXPIRES: 2/15/2022
TOTAL:$136.00
Issued Date:8/19/2021 2 of 2
....--,..,..,,o,., Plumbing Permit Application **ALL INFORMATION
1(5I.'. HIGHLIGHTED IN
, City of Atlantic Beach Building Department GRAY IS REQUIRED.
�',:)c I 800 Seminole Rd, Atlantic Beach, FL 32233
'`.''_ Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#:
JOB ADDRESS: 0t'Vl T•n ,y N4 f4.4irrN}ic l3 mi., 11-'¢ PROJECT VALUE$ Zo,cx ,"'
❑NEW OR REPLACEMENT INSTALLATION and/orikRE-PIPE
TYPE OF FIXTURE QTY TYPE OF FIXTURE QTY
Bathtub 1 Septic Tank& Pit J
Clothes Washer t Shower I ,
Dishwasher t Shower Pan I •
Drinking Fountain cif Slop Sink qf
Floor Drain 0 Three Compartment Sink cd
Floor Sink 0 Toilet t -
Hose Bibs . Urinal 0
Kitchen Sink • f • Vacuum Breakers >6
Laundry Tray • 1 Water Connected Appliances Cr
Lavatory • i . Water Heater , t
Other Fixtures Water Treating System P
❑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: (bcut ic, tPeAV,vi Phone Number:(cio4-0 Z.,i- 2.3s5
Plumbing Company: Cic..c{ rcc,,ac.` t skr romi-inc. Office Phone: (go-0 6W-9G4,,to Fax
Co. Address: P. P u L1,14 City: (Yl`AlltAc,r5 State: r'1 Zip: 3zinst
License Holder: 1•441r $.}lot State Certification/Registration # OFC t4S0S480
Notarized Signature of License Holder / qr
The foregoing instrument was acknowledged before me this _11 day of AUGUST , 20 24, in the State of Florida,
County of 0UVAL-
71-7.•�Y. '•
CHRISTIAN GILES 2.6
'''' `: Signature of NotaryPublic 1
cu ;,, MY COMMISSION#HH 117153 g 1�/I. /
.4 .%"k.•47EXPIRES:Apri113,2025
''•'i'f.%: ' Bonded MNNoaryPubic Ur�erw1lbrs [ ) Personally Known OR [ Produced Identification
.usrrii'ns+r
Type of Identification: Ft, pL
Updated 10/17/18