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E mail address E Mail Address Ci V r ¢ D rrtei a 1.GCl t l� Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION- 12 Digit Parcel No - Fire District Legal Description _ Site Address(Please include street name,street number and city Directions to site Is property within 200'of Saltwater Lake River/Creek Pond Wettand Seasonal Runoff Stream Slopes or Bluffs > 15°k TYPE OF JOB-New_Add_Alt Repair_Other Use of Building Location of Fixtures/Units-1 at Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No.of Fixtures Fees Fuel Type:Electnc_LPG_Natural Gas_Heat Pump_ Toilets Tvoe of Unit No.of Units Fees Bathroom Sink Furnace Bath Tubs He Vum sher Spot Vent Fan an AID Heater Propane Tank �\ Clothes Washer Gas Outlets Kithen Sinks Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL OWNER/BULDER Acknowledges stxxrossion of inaccurate information may result in a stop work order or pernit revocation.Acknowledgement of such is by signature below.I declare that I am the owner,owners legal eve,or the contracW.I further declare that I am entitled to receive this pem*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 holder or arty other party in interest regarding this application or the work proposed in the application,I have obtained permission from Own to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the Information providad is accurate arg grants ernployees of Mason County Wiese to the above described grope and structure for review and inspection. OF V9RK IS BY MEANS OF A PROGRESS INSPECTION. X Oate: owner!RmnerpAsoeswitative i Contractor (indicate which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by Planning Pd Ck# Qate '7.iV-1 Bid Pd Receipt No. DEPARTMENTAL REVIEW ApP OVED DENIED NOTES Building Department Ooc Group T onstr. 7" Planning Department Environmental Health Department FEES Ewvltolation bin &Base Fee Site In ion anhcai&Base fee UFC Plan Review Fee d/Gas 1 Pellet Stove Fee Other Fee TOTAL FEES