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Permit No/ g�
MASON,COUNTY
4 PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar/P.O.Box 186, Shelton,WA 98584.427-9670
PLEASE PRINT
#1 Owner Phone#
Site Address C5—: V- 2
City /
Directions to JoibtecD �--
L � � O C=M4 MWIFS
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Owner Mailing Address %b
City Q1.LU St W4, Zip Cl 2 6"Z4
Lien/Title Holder FLCV-:'t"- %=y}1A 1 NC
Address
City St-R.a" ip
#2 Contractor Name Contractor Reg.#
Address Expiration date
City St Zip Phone
#3 Parcel No. 3 - -_ -
Legal Description
#4 Use of building Describe work
#5 Type of Job: New. Add Alt Repair
Plumbing Fixtures ($3 eachl FQQ Mechanical Fix#ure& aeachi' -r
No._Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
_Bath'Tubs NQ., Units Fees
Showers Furn BTU
_Hot Water Htr _ Heatpumps
_Laundry Washer _ Vent Systems
_Sinks Spot Vent Fans
_Floor Drains Ng,, Boilers/Compressors
_Laundry Basins HP
_Dishwasher Ng Air Handling Units
_Disposal cfm#
_Urinals Ngg Other
_Other _ Outlets
L Wood, , Pellet Stove
Permit Basic Fee 15.00
TOTAL PLUMBING $ _
Permit Basic Fee 15.00
TOTAL MECHANICAL
NOTICE; This permit becomes null and void if work or construction authorized is not commenced
within 180 days or if construction or work is suspended or abandoned for a period of 180 days at any
time after work is commenced. Proof of continuation of work is by means of a progress inspection.
NOTE: If this permit application includes the placement of a fuel tank, heat pump or other unit to be located
outside of the existing structures, a plot plan MUST be submitted as required below:
Show following on the site plan below: Lot Dimensions,Existing Structures,Structure Setbacks,Water Lines;Septic Systems,
Flood Zones, Wells, Shorelines, Easements, Name of Flanking& Fronting Streets. Indicate directional by N, S, E, W, etc.
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OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRAC-
THE CONTRACTORS REGISTRATION LAW RCW 1827,AND AM TOR IN THE STATE OF WASHINGT:,ON AND I AM AWARE OF THE
AWARE OFTHE MASON COUNTYORDINANCE REQUIREMENTS ORDINANCE REQUIREMENW R"ULATING THE WORK FOR
FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WOR,��,�C WHICH THE P.ERMIT,Ih1SeUED ANC ALL WORK DONE WILL BE IN
DONE WILL BE IN CONFORMANCE THEREWITH.NO ONANt�sES" GONFE�RM TH A(4cE EREWITH: N6 CHANGES SHALL BE MADE
SHALL BE MADE WITHOUT FIRSTOBTSMNING APPROVAL FROM WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDIN EPARTME DEPARTMENT.
X OWNER atm X BY
DATE DATE
Return permit to: Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 . 427-9670/1-800-562-5628
Y.
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DEPARTMENTAL REVIEW proposal Proposal
FOR OFFICIAL USE ONLY Approved Denied
Planning:
Building:
Fire Marshal: