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o CONCRETE MECHANICAL MANUFACTURED HOME
CD Date By
Footings I Setbacks Gas Piping Ribbons 0
C) Interior Date By Interior-Date By Data By 0
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0) Set-up 0
Point Load I Isolated Footings INSULATION Date By
Date By BG I SLAB INSULATION FIRE DEPARTMENT C
Date By 0
Foundation Walls Floors Date By M
Date By Data By DECKS
FRAMING Walls Date By
Date BY Data By PROPANE TANKS
PLUMBING Vault Date By
Date By OTHER
Groundwork Attic
Date Data By Type-
By Date By
DWV DRYWALL Type.,
Date By Int Brace Wall D yIp
Grate B
Date By
CD - FINAL INSPECTION 0
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W Water Line Fire Seperation
CD @ Date By Date By Data By CD
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Type of Insp. Fail Date Date Dane By Comments
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MASON COUNTY RECEIVED
J COMMUNITY SERVICES (�
Building,Planning,Environmental Health,Community Health �`A Y 2 4 2017
Physical and Mailing Address: 615 WAlder St.,Bldg 8, Shelton, WA 98584 615 W. Nder Street
Shelton Phone: (360)427-9670 ext 352 4• Fax (360)427-7798
PLUMBING & MECHANICAL PERMIT APPLICATION Permit#: B l W IV
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:(".'- ! C - _ NAME:
MAILING A ESS:' MAILING ADDRESS:
CITY: STATE: ZIP: CITY: STATE: ZIP:
1st PHONE:T(,,c'� _ A7S, 9:ZT� PHONE: CELL:
2nd PHONE: EMAIL:
EMAIL:E�A- a.I� V A � , oh, L&I REG# EXP. l I
PARCEL INFORMATION: 2
PARCEL NUMBER (12 Digit Number): I Z 33a _10 5 3—0d0 1 Zoning:
LEGAL DESCRIPTION (Abbreviated:
SITE ADDRESS.—,O' S✓R 1J TtR 6YI Pt Ct CITY: Q 1
DIRECTIONS TO SITE ADDRESS: P 16 Tv S' 1 L C..i�
TYPE OF JOB/WORK: NEW ADD ALT REPAIR OTHER
USE OF BUILDING
PLUMBING FIXTURES MECHANICAL UNITS [] Electric in-wall heaters(no fee)
Type of Fixture No. of Fixtures Fuel Type Fees Type of Unit No. of Units Fuel Type Fees
Toilet(s) Furnace [E/G/LPG]
Bathroom Sink(s) Heat Pump [E/G/LPG]
Bath Tub(s) o Ductless H.P. [E/G/LPG]
Shower(s) Spot Vent Fan
Water Heater(s) 3G/LPG] Propane Tank
Clothes Washer(s) [E/G/LPG] Gas Outlet(s)
Kitchen Sink(s) Heat Stove [E/G/LPG/W]
Dishwasher(s) Kitchen Exhaust Hood
Hose bib(s) Dryer Vent
Other Solar Panel
Other Other
Plumbing Subtotal Mechanical Subtotal
Plumbing Base Fee Mechanical Base Fee
Final Inspection Fee Final Inspection Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDER acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is
by signature below. I declare that I am the owner,owners legal representative,or contractor. I further declare that I am entitled to receive this permit and to
do the work as proposed. I have obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this
project.The owner or authorized agent represents that the information provided is accurate and grants employees of Mason County access to the above
described property and structure(s)for review and inspection.This permit/application becomes null&void if work or authorized construction is not
commenced within 180 days or if cKn-sVuctio5,Work is suspended for a period of 180 days.PROOF OF CONTINUATION OF WORK IS BY MEANS OF
X �7ACTIVITY OF T IS E TR PPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
6Z
-x 0 igna ure of 11 t
CJ - . -- __-_ ___ wn_er_ WneTs Re rese.ntativel_Contractor
Print Name (Circle one)
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
O Building
O Fire Marshal
O Permit Tech (OTC permit only)
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