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' PERMIT N0F7LD201 1-0019 1
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar- P.O. Box 186, Shelton,WA 98584
Shelton (360) 427-9670-Belfair(360) 275-4467- Elma(360) 482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION,
Owner'?veatg" In, X 'Il / Company Name
Mailing Address Mailing Address � � J
City ' =a..�r Stater Zip Code City �2i� '1Z-State -4. — Zip Code
Phone--5�.ii S-,77- Y It/`S Other Ph.!1-,e --zl9a-tlV-37 Phone.34A -}'3?'-020f--3 Other Ph.
Lien/Title Holder Contractor Reg. ` xp.
E mail address T-gin dy A4flr- oel r E Mail AddressQK``
Drivers Lic.#j�a,.ro1-r,K: 74 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 112 --rb ::LC -d✓� g*, 1/ 5 .t//� ��r f' 77�— % �l lol-
ls property within 200'of Saltwater .41.2 Lake River/Creek � Pond P
Wetland • 4/ Seasonal Runoff--,Z-42 Stream,La—Slopes or Bluffs > 15%
TYPE OF JOB - New Add Alt Repair Other Use of Building
Location of Fixtures/Units - 1st Floor Td Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric_ LPGi_ Natural Gas Heat Pump_
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank
Clothes Washer Gas Outlets
Kithen Sinks Wood/Gas/PelletStove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base 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 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 holder or any other party in interest regarding this application or the work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROOF F ONTINUATION OF W RK IS BY MEANS OF A PROGRESS INSPECTION. / 1
X - Date:_ /l`�/ ]�
Owner/Owners Representative Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group—Type Constr.
Planning Department
Environmental Health Department
FEES
Plumbing & Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES