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FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD PERMIT NO.:
MASON COUNTY •���
PLUMBING/MECHANICAL PERMIT APPLICATION
Shelton(360)42 9670/Beellf ir(3606�754467'Elma9360)482-5269
APPLICANT INFORMATION CONTRACTOR INFORMf JJON
Owner /a /-.W Contractor Name �IWA 40<41116- 1_414 rc�r,.n� iCG�
Mailing_gddress G Mailing Address
City ` iA State OX Zip Code If City State Zip Code
Phone . -'73r1Z Other Ph. Ph.(340 Other Ph.( &a );1J'-6.33-
Lien/Title Holder Contractor Reg. # Jr-
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 d' it Marc I No. .� / Fire District
Legal Descriptio M"- -b /
Site Address(Pleas include street n_afj�'s reet numb d city) 17
Directions to sit r�/' 1 �' c�2 �'P �i� D
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 Other Use of Building
Location of Fixtures/Units 1 st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures Fees LPG Natural Gas Heatpump
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer Gas Outlets
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee
TOTAL PLUMBING 97- 00 TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&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-[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
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
)( Dat X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Dat ubmittal Amount Due Receipt No.�
..
DEPARTMENTAIIR E:. IiPPRFaVEp GORIfTt#IQN CODES
a)Z:NIEtJ
Building Department
Occ Group Type Constr.
Planning Department
Other
Other RE
Permit Fee Site Inspection 3
Plan Review Fee UFC Plan Review Fee 426
Plumbing&Base Fee Other .
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES