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Date By D Date By FINAL INSPECTION m Water Line Date Ojpl By B ate By i Date B y 4 He.-,tee 0 O 0 I N O O O O O 0 � O y N CD O � N o ►-C o � o y r y 00 0 FORM MUST BE COMPLETED IN INK + PLEASE PRESS HARD MASON COUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar/P.O.Box 186 Shelton,WA 98584 Shelton(360)427-9670 Belfair(360)�75-4467 Elma(360)482-5269 PPLICANT INFORMATION CONTRACTOR INFORMATION wrier r%"�3 �. L-.n! f i o . � J4,7w Contractor�ame Mailing Address -e) S9 Mailing Add ess ram© i City &a State j,J/4 Zip Code `S""b' City d State ,(,l _ Zip Code Phone c--c Other Ph. « Ph. 36u 7-7 " i Other Ph.( ) Lien/Title Holder -7'71 Contractor Reg. # C DCN Address Expiration SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION- 12 digit Tax Parcel �/ / `E� / C�fSa Fire District /6 Legal Description 41 7 se 741-) Site Address (Please include street name,street number and city) Directions to site E — c v i Tv i? r. ;s i2c+` o C%�is t L Is your property within 200'of the following: Body of Water(Name) .1d Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs r TYPE OF JOB New V"i 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 X Natural Gas Heatpump Toilets Tvoe of Unit No.of Wad Fees Bathroom Sink Furnace — Bath Tubs Heatpumps Showers Spot Vent Fan Water Heater Propane Tank G Clothes Washer Gas Outlets Kitchen Sinks Wood/Gas/Pellet Stove Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent Other. Other —�-- �� Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL 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 OR 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 that the information provided is accurate and grants employees of Mason County access to the above described property and structures for review and inspection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 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 ordinance requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without appro first obtaining approval. Date /- C)y X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. AEPE#RTMEIVT RE1l EVY APPFtt VED R1"IVIEf7: GONDITIOI l GQRES Building Department Occ Group Type Constr. Planning Department D 000157V -- Other F' a a-}'-0-e y, Other 777 Ic1wS:: a<<::>:> .......... ::..._....._:................ 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 ) S Violation Fee TOTAL FEE (�