HomeMy WebLinkAboutMIS99-00202 Propane - MIS Permit / Conditions - 4/23/1999 M _
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- MASON COUNTY PERMIT NO.:
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 Seattle 206 464-6968
APPLICANT IN ORMA IJ CONTRACTOR INF RMATION
Owner 19-11 ?��r / Contractor Name �°ri r tfe r1 5
Mailing yid 1 S',eT
c �f 4 Mailing A dress 6 bpi, a,�f .a .
City .S - Stat Zip Code City �t i State 1, 4 Zip Code
Phone( ?6o ) -5ZY Other Ph. Ph. d -I. 41 Other Ph.( )
Lien/Title Holder 4U us . Contractor Reg. # Alfccc ll oc s
Address W 9 So l Expirations/ /
SEPTIC INFORMATION-Connect to New Septic Existing Septic X Connect to Sewer System N me of
Sewer System
PARCEL INFORMAT,I.ON-12�Iigi�T�x Pafce)No t' / ! Fire District
Legal Description ' () - x C r
Site Address(Please include str et n me, s et n mbe and it C oa�+G c��
Direction/ to site �1 cA� r - a+s ,-/
%" _ .—,5
Is your property within 200' of the following: Body of Water(Name) Saltwater c�
Lake nlc> River/Creek lul," Pond A& Wetland A*-> Seasonal Runoff u- Stream AA, Slopes or
Bluffs,^4(b
TYPE OF JOB New ZY Add Alt, Repair Other Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No. of Fixtures Fees LPG Natural Gas Heatpump
Toilets Type of Unit No. of Units F ees
Bath Basins Furnace
Bath Tubs Heatpumps
Showers Vent Fans
Water Heater Propane Tank
Laundry Wsher, Gas Outlets
Sinks Wood/Gas/Pellet Stove�—
Dishwasher Direct Vent?
Other Other
Other Other
Base Fee - /TaTT—Base Fee
TOTAL PLUMBING YI TOTAL MECHANIC
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS C R IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents I hat the
information provided is accurate and grants employees of Mason County access to the above described property and structures for revi w and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordi ance
requirements for which this permit.' 'ssued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval c' first obtaining approval.
Date — X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
UEARTMEI\1TigE#iE.W::> AR [ti]VEQ :.; iJt:N1Ef}.:.:;..::::...::.::.;:.,::, .. :':'::.;:.CORTCIiTLQN CrQR�S
Building Department
Occ Group Type Constr.
Planning Department
Other
Other
5»»`: ii�i''<ii'" i <i ;<i%:' >»`%i5i»''iii>:?E>:< >zE>»»>�»iXWXiY<`iii;iii% i»»»>:%>#
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other .� {
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal
Violation Fee TOTAL FEES
uF.r t4 '��:.r .yxy,. :�,. �9--�.:Z'..; vu-�,,L_;, 's'+ r ,�.,-.•--ca..-„-,- .°may-rpH. �m �;,sf:r.
MASON COUNTY PROJECT SITE INFORMATION
� Case No.
Name_/ j`1 f" PARCEL NUMBER Date
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S. E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Sbtbacks Shorelines S,
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
Names'of Fronting Streets Septic System ✓
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line
adjacent property lined I , <-adjacent property 1 ne
,7
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a cent ro eit rtfihe4 Fad'acent propeqylie
SAMPLE SITE PLAN
adjacent property like--? D 3Zo' 30 r ROE _ Fadjacent property Ii e
1
SEALS.wi A" 1 a L
MOM t fi Cs--
I ao PostD �^ sn ptt t --�1
1 1
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VACANT
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3o P0.oPmGD 1 f
1 y A6RsCY.LTu.RAL
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adjacent property lined i Fadjacent propert'line
TOPOGRAPHY PROFILE(Show aside view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.)
SAMPLE TOPOGRAPHY PROFILE
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do/c-o,> 74
� dis+annQ
Signature Date