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COM2003-00026 Final Medical Gas Install - COM Inspections - 3/3/2003
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Date By Date By FINAL INSPECTION Water Line Date .& 0:3, B yT Date By �# Date By O c, IR Of C166 � r b N Cl'J O W i O N G1 w 0 h w FORM MUST BE COMPLETED IN INK PERMIT NO.: PLEASE PRESS HARD MASON COUNTY G0 2 Z' PLUMBING/MECHANICAL PERMIT APPLICATION • 426 W.Cedar/P.O.Box 186,Shelton,WA 98684 2bp • Shelton 60 27-9670 Belfair 360 276.4467 Elma 360 82.5269 Seattle 206 64-6968 y APPLICANT INFORMATION CONTRACTOR INFORMATION �J �� Owner _ Contractor Name i ?j Mailing Addr Mailing Address y 9 City P& JbILY State" Zip Coe Cit State Zip Code ✓l- Phone( Other Ph.( Other Ph.C___) V Lien/Title Holder Contractor R # �— Address Expiration e SEPTIC INFORMATION-Conned to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION- digit Tax Parcel No. / / Fire District Legal Description Site Address(Please inc ude street n e, a numb and city) Directions to site 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 1st Floor 2nd Floor Basement Garage Close 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 Bath Basins Furnace Bath Tubs Heatpumps Showers Vent Fans Water Heater Tank Laundry Wsher Gas Outlets /0_ Sinks Wood/Gas/Pellet Stove Dishwasher Direct Vent? Other Other Other Other 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 d,VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF o l, 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-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that 1 am currently registered as a n 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 (i[� 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. ` X Data Dirties? FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. Building Department Dec Group, T Corstr. Planning Department Other Q� ©.tip i�1�✓� Other n:t3 Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing&Base Fee Other Mechanical&Base Fee Other Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal Violation Fee TOTAL FEES silverdale plumbing & heating inc. LETTER OF TRANSMITTAL TO: Mason County DATE: 10-Feb-03 Community Development JOB: Dr. Le ere Dental - Belfair P.O. Box 186 RE: Medical Gas Piping Permit Shelton, WA 98584 WE ARE SENDING YOU THE FOLLOWING ATTACHMENTS: Copies Date No. Description 1 Floor Plan 1 Oxygen and Nitrogen Piping Diagram 1 Permit Application I cz tinn _%- S THESE ARE TRANSMITTED AS CIRCLED BELOW: For Approval As Requested Resubmit REMARKS: Please let me know as soon as possible if any more information is needed for the permit for this project. Please call if you have questions. COPY TO: File SIGNED: `� Michelle Gonzalez 11875 Silverdale Way NW, Suite 104 • Silverdale, WA 98383 •(360) 692-8840 • Fax (360) 692-1867