870 SAILFISH DR PLRS21-0141 Plumbing Permit Application **ALL INFORMATION
HIGHLIGHTED IN
(--- . City of Atlantic Beach Building Department GRAY IS REQUIRED.
101E,
800 Seminole Rd, Atlantic Beach, FL 32233
Phone: (904) 247-5826 Email: Building-Dept@coab.us PERMIT#: I J [ `}c /,,, '
JOB ADDRESS: 10 Sal,Cisk DV VE kr\ C' PROJECT VALUE $
6eCt.Ck aHOD
1NEW OR REPLACEMENT INSTALLATION and/or ❑RE-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 V Toilet ✓
Hose Bibs Urinal
Kitchen Sink Vacuum Breakers
Laundry Tray Water Connected Appliances
Lavatory V. Water Heater
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.
---ROwner Name: t e V&VQ Phone Number6-5j G-(oq—c,-- Q i 1
Plumbing Company: ()LAD(\ Q ( Office Phone: Fax
Co. Address: QL1(\, Q_____ City: State: Zip:
License Holder: State Certification/Registration #
Notarized Signature of License Holder ,C Pb.-L, �a�k O
The foreg instrument as acknowledged b ore me this I,(7) &tp...---- , 202,lin the State of Florida,
County of 0r
a
Signature of Notary Publi a-
10-------
�,;,Ycye4c; TONI GINDLESPERGER
*.r il •.,, MY COMMISSION#GG 353178 [ ] Personally Known OR [ ] Produced Identification
=°a• ;°�..� EXPIRES:October6,2023 , Type of Identification: . l-_-_
-'°F9F F""- Bonded Thru Notary Public Underwriters
Updated 10/17/18
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