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12-10-12; 21 :25 13604,277798 # 2/ 2
MASON COUNTY PERMIT
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar•PO.Box 186, Shelton,WA 96584
Shelton (360)427.F70•Belfair(360)275-4467•Elma(360) 482-5209
n the we www.co.mason.wa.us
XPPLICA INFO ADO�NutFuA4 CONTRACTOR IN RMATION
owner M Company NameVA^►«n �wr -✓� i�� -I[,
Mallln Addresses 0 IA(. Ld E BOVWX Mailing ddress #0
City 5tate MI—Zip Code C, I tat WA Zip Code��L
Phone Jo 470, I)II&�--Other Ph. Phone a Other Ph.
Lists/Title Holder Contractor Reg. Exp.. �3
E mail address EMailAddress�A���� rH7 ��+n�I eh
Drivers Lie.# _ DOB_, _ I Drivers Lie.k DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION- 12 Digit Parcel No. —I I - 7L Fire District
Legal Description
Site Address(Please include street name, street number and city) LtIfT 1 &kli�E7_
Directions to site
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff—Stream—Slopes or Bluffs > 16%
TYPE OF JOB - New_Add_Alt,._Repair Other Use of Building
Location of Fixtures/Units- 1st Floor 2nd Floor Basement Garage Closet
P UMBING FIXTURES(Show Number of each) MECHANICAL UNITS
T4De of Fixture No. of Fixtures Fees Fuel Type:Electric� LPG_ Natural Gad_ Heat Pump—
Tci Type of Unt No. of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer!LPLUMBINJ
Gas Outlets
Kithen Sinks Wood(Gas/PelletStove
Dishwasher Kitchen Exhaust HoodHosebibs Dryer VentOther Other
Base Fe Base Fee
I TOTAL MECHANICAL
OIMVER/GUIDER Acknowledges submission of inaccurate informailon may result in a stop work order or pemrit revocation.Admowtedgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the permission from all the necessary parties,If permission is
required from any easement holier or any other party in Interest regarding this application or the work proposed in the application,I have dRained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the infonnation
provided is accurate and grants empbyees of Mason County access to the above described property and soucture for review and inspection.
PROOF OF ATI F WORK IS BY MEANS OF A PROGRESS INSPECTION.
X Date:I_ll(J-11 A
Own n s Representative/contractor (Indicate which one)
FOR OFFICIAL USE BEYONDTHIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Reeelpt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Qcc Group—Type Constr.
Planning Department
vironmental Health Department
FEES
Plumbing& Base Fee Site Inspection
Mechanical&Base fee 1UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee 10ther
Violation Fee TOTAL FEES