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04/11/2011 08: 39 3604277466 OLYMPIC H �T*ING PAGE 01/01
FORM MUST BE COMPLETED IN INK PERMIT NO.. L�
PLEASE PRESS HARD MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar- P.O. Box 186, Shelton, WA 98584
Shelton (360) 427-96710 • Bel a'r(360) 275-4467 • EI a (360) 482-5269
On the we www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR I ORMATION ,
Owner ( Company Nam
Mail' Addres �� Mailing Address
City Statet.A)A Zip Code City Late — Zip Code
Phone -3-25-9 l I-QZ8 , Other Ph. Phone Other Ph.
Lien/Title Holder Contractor Reg. tit`AMP q� &Exp.
E mail address E Mail Address
Drivers Lic.# DOB Drivers Lic.# DOB
SEPTIC INFORMATION - Connect to New Septic Existing Septi Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION - 12 Digit Parcel No. ._ ---AQLSJI Fire District
Legal Description
Site Address (Please include street name, street number and city,)
Directions to site
Is property within 200'of Saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs! 7 15%
TYPE OF JOB - New Add Alt Repair Other Us of Building
I Location of Fixtures�Units- 1 st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL,UNITS K
Type of Fixture No. of Fixtures Fees Fuel Type:Electrc— LP — Natural Gast 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/PeJI0Stove
Dishwasher Kitchen Exhaust� ood
Hosebibs Dryer Vent
Other Other -------
Base Fee Base Fee ' 1
TOTAL PLUMBING TOTAL MECHANICAL
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop w rk order or permit revocatl=Acknowledgement of
such`is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further doplare 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
raqUired from any easement holder or any other parry in interest regarding this application or the ork 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 pro erty and,structure for review and inspection.
PROO O CO NU OF O K IS BY MEANS OF A PROGRESS INSPECTION.
X r
Date: t
Owner/Owners Representative/Co tractor (indicate which one) r �
FOR OFFICIAL USE BEYOND THISIPOINT
Accepted b ` n L Planning Pd Ck# Date`-) It Ze,t I Bid Pd Receipt No.
DEPARTM NTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group—Type Constr—
Planning Department
Environmental Health Department
FEES
Ptumbin & Base Fee Site Inspectlorli
"Mechanical & Base fee UFC Pian Revi w Fee
lwood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES