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_ 1
Permit No. _
• MASON COUNTY'
PLUFABING/MECHA,NICAL PER IT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, OVA 9 584.427-9670
PLEASE PRINT
#1 Owner_], ��__..—._ _ Phone#
Site AddressU -
city #� I, e A j3=-11 I I _St-Ii LAS h zipele E; .
Directions to Job Site
i
Owner Mailing Address 40 q,? _
City_... _..__ St zip
Lien/Title Holder
Address
city St z111._
#2 Ccri ractor Name Contractor Reg. # _
Address Expiration date _
City St WAS Ip 5'S3'5 Phone
#3 Parcel No. - -
Legal Description _
#4 Use of building s Describe work 1_� .6".
#5 Type of Job: New Add Alt Repair
Plumbing Fixtures ($3.35 each) Fee Mech ical Fixtures ($6.75 eachi
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatp mp, Other
Bath Tubs No. Units Fees
Showers _ Furn BTU_
_Hot Water Htr Heatpumps _
_Laundry Washer _ Vent Systems
_Sinks _ Spot Vent Fans _
__Floor Drains No. Boilers/Compressors
_Laundry Basins _ HP
_Dishwasher No. Air Handling Units
_Disposal _ cfm#
Urinals _ No. Other
_Other _ _ Gas Outlets
Woo , Ga)Pellet Stove 33.00
Perm'st BasJ3 Fee 16.75
TOTAL PLUMBING $ _
Permft Basic Fee 16.75
TOTAL MECHi'�\NICAL $ ,�5
No Basic Fee for Wood, Gas, Pellet Stove
NOTICE: This permit becomes null and void if work or construction authorized is not commenced
within 180 days or if construction or work is suspended or abandoned for a period of 180 days at any
tin-ie after work is commenced. Proof of continuation of work is by means of a progress inspection.
NOTE: If this permit application includes the placement of a fuel tank, heat pump or other unit to be-located
outside of the existing structures, a plot plan MUST be submitted as required below:
Show following on the site plan below: Lot Dimensions, Existing Structures, Structure Setbacks, Water Lines, Septic: 'ystems,
Flood.Zonos, Wells, Shorelines, Easements, Name of Flanking & Fronting Streets. Indicate directional by N, S, F, W, etc.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
1 CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF �I CERTIFY THAT a AM A CURRENTLY REGISTERED CONTRAC—;
, THE CONTRACTORS REGISTRATION LAW RCW 18.27,AND AM TOR IN THE STATE OF WASHINGTON AND I AM AWARE OF THE
AWARE OFTHE MASON COUNTYORDINANCE REQUIREMENTS ORDINANCE REQUIREMENTS REGULATING THE WORK FOR
FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WORK WHICH THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
DONE WILL BE IN CONFORMANCE THEREWITH. NO CHANGES CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE;
SHALLBE MADE WITHOUT FIRST OBTAINING APPROVAL FROM WITHOUT FIRST OBTAINING APPROVAL FROM THE �+UILDING''
THE BUILDING DEPARTMENT. DEPARTMENT.
X OWNER X PY
DATE 'DATE
Return permit to: Department of General Services
.426 W. Cedar/P.O. Box 186, Shelton, WA 985'84 427-9670/1-800-562-5628
��3R 41=F'IGIAI.�JSE{ NIA Y. recce feel b . � � k r 5
p:. Y bate:
i
13ecelpt Colo Referred n
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY Proposal Proposal
- Approved Denied
Planning:
i
Building:
Fire Marshal: