HomeMy WebLinkAboutCOM2003-00005 Plumbing/Mechanical - COM Application - 1/9/2003 FORM MUST BE COMPLETED IN INK PERMIT NO.: _,�M�+
PLEASE PRESS HARD MASON COUNTY n/(�� a�U/1 s
PLUMBING/MECHANICAL PERMIT APPLICATION �J(� VV
426 W.Cedar/P.O.Box 186,Shelton,WA 98594
Shelton 360 4279670 Belfair 360 275-4467 Eli 360 4825269 Seattle 206 4"-6968
APPLICANT INFO M TIO CONTRACTOR INFORMATION
Owner I r Contractor Name Lb0fj2 tI;A 014V Ine.
Mailing Address I 10 1 L Mailing Address
City k)nton State a Zip Code d� City _State Wc—, Zip Code
Phone( Other Ph.(_ Ph.(a`3 ) ' - Other Ph.(.IS 3 ) 1-
LienlTitle Holder Contractor Reg.# - L-
Address Expiration /_1 / 05
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name off
Sewer System 1
PARCEL INFORM�ITION-12 digit Tax Parcel No. 33 !� / OOP 1 Fire District 1 OT
Legal Description_ lrl h Lo�S 10— 1 * o
Site Address(Please includb street name,street number and city) O 1 vJ O
Directions to site S
bY' i✓n 4e s-Chi 6n�, -
Is your property within 200'of the following:Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New_Add Alt Repair Othe Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fue T lectric
Type of Fixture No.of Fixtures Fees LPG Natural Gas eat ump
Toilets Type of Unit No.of Units Fees
Bath Basins Furnace
Bath Tubs Heatpumps 27747
44 Showers Vent Fans
Water Heater Propane Tank
Laundry Wsher Gas Outlets
Sinks Wood/Gas/Pellet Stove
Dishwasher Dire^� �1t?
Other Other
Other Other i
Base Fee Base Fee �%
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL a VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
Inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirement for which thispermit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
confo r}c therewith. tan es shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
apW 7 / first obta' i approval.
�( rl Date
--7—T I "/,L
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
bE'PARTMERTAt ltMew D NIEtF CONDITION CODES
Building Department _ - ✓�`
^/k Dec Group. Type Constr V
Planning Department `
Other . Qi
Other Q
Q
Permit Fee Site Inspection
Plan Review Fee 1 3721
UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee C Other
�.�Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( 19-9.OP
Violation Fee TOTAL FEES