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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date I by INSULATION date by
BGISLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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P i'mit �
MASON COUNTY No.
•PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584. 427-9670
PLEASE PRINT
#1 Owner Phone#
Site Address y,3Z L13� Ar
City _�.1 toa WA St I-A Zip f?_512
Directions to Job Site k�,,A L'vn' �2 pNPie
✓Q
Owner Mailing Address S ;,)
City TS St Zip
Lien/Title Holder
Address
City St Zip
#2 Contractor Name Contractor Reg. #
Address Expiration date
City St Zip Phone
#3 Parcel No.
Legal Description _
#4 Use of building (agQg66 Describe work
_(_-yraU iX. 0,9� j2l iv( "G �►IJ I��cs k�
#5 Type of Job: New_!K Add Alt Repair
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
_Bath Tubs No. jj!]iM Fees
1 Showers _ _ Furn BTU
Hot Water Htr Heatpumps
_Laundry Washer Vent Systems
Sinks R _ _ Spot Vent Fans
_Floor Drains No.. Boilers/Compressors
_Laundry Basins Hp
_Dishwasher No. Air Handling Units
_Disposal cfm#
_Urinals No.. Other
_Other Gas Outlets
Wood, Gas, Pellet Stove
Permit Basic Fee 15.00
TOTAL PLUMBING k—
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.
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 18.27,AND AM TOR IN THE STATE OF WASHINGTON AND I AM AWARE OF THE
AWAREOFTHE MASON COUNTYORDINANCE REQUIREMENTS ORDINANCE REQUIREMENTS REGULATING THE WORK FOR
FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WORK WHICH THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
DONE WILL BE IN CONFORMANCE THEREWITH.NO CHANGES CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE
SHALL BE MADEWITHOUT FIRSTOBTAINING APPROVAL FROM WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTMENT.
X OWNER _ 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
xv-
FOR OFFICIAL USE ONLY: Accepted by: Date:
Receipt No. Referred To
DEPARTMENTAL REVIEW Proposal Proposal
FOR OFFICIAL USE ONLY Approved Denied
Planning:
Building:
Fire Marshal: