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Faits Date [date Done By Comments 0 (D U) 0 0 Z, 0 En 0 C/) ———---------------------- (D 0 MASON COUNTY PERMIT NO.FGALi3-role u( PLUMBING/MECHANICAL PERMIT APPLICATION 426 W. Cedar• P.O. Box 186, Shelton, WA 98584 Shelton (360)427-9670•Belfair 1360)275-4467•Elms(360)482-5269 On the web w co.mason.wa.us APPLICANT INFORMATION CONTRACTOR INFORMATION Owner lsc k'z�n L"i Company Namefl �� � '� %ram Mailing Address \)o 1� W; 12 Mai T g Address. �����"� �S� City`2— State v LCa Zip Code c'W-- Citgt State t Zip Code L 1 Phona"�L j 2� 3 1 Other Ph. Phone-��L ) �1 ? T-' Other Ph. Lien/Title Holder Contractor Reg. Ac)�A_v N' , Exp. E mail address E Mail Address CV-4-\k (Ea' `,'. 'ocg: „`;l ,cc,v Drivels 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 - LF4- Fire District Legal Description Site Address(Please include street name, street number and city) t lo,v Directions to site Is property within 200'of Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs > 15% TYPE OF JOB- Newer Add_Alt_Repair_Other Use of Building Location of Fixtures/Units- 1 at Floo 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Electhc_LPG_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/Pellet Stove 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 pro ed is aocu and grants employees of Mason County access to the above described property and structure for review and inspection. PRPOF COI T1NU TION OF WORK IS BY MEANS OF A PROGRESS INSPECTI N. Date: Ow /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—T a Constr.— Planning Department Environmental Health Department FEES Plumbina& Base Fee I Site Inspection Mechanical & Base fee UFC Plan Review Fee Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES