HomeMy WebLinkAboutBLD2007-01736 PROPANE - BLD Permit / Conditions - 10/1/2007 t
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FORM MUST BE COMPLETED IN INK MASON COUNTY PERMIT NO.C _a �
PLEASE PRESS HARD
PLUMBING/MECHANICAL PERMI APPLICATION
426 W. Cedar•P.O. Box 186, Shelton, A 98584
Shelton (360) 427-9670•Belfair(360) 275-4467• Ima (360) 482-5269
On the web www.co.mason.wa.L:S
APPLICANT INFORMATION,_ CONTRACTOR INFORMATION
Owner Company Na e
Mailing Address 1 I g Mailing Addr ss
City State j,' Zip Code -�1-4 City State Zip Code
Phone6 `:--y �L7cf;3 Other P Phone Other Ph.
Lien1_TftW-ceder Contractor Reg.# Ex .
P
E-nia+acldress E Mail Address
uers_-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. - Fire District 7/
Legal Description S R a C-1C ,r W-r _T r r Q<
Site Address (Please include street name, street number and city)
Directions to site
Is property within 200'of Saltwater Lake River/Cr ek Pond
Wetland Seasonal,flunoff Stream Slopes or Bluffs 1 15%
TYPE OF JOB - New L Add Alt Repair Other Use of Building
Location of Fixtures/Units - 1 st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric— LPC�_ 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 1 , _
Clothes Washer Gas O s i p
Kithen Sinks Wood/ as el tStove I
Dishwasher Kitchen xhau t 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 vork order or permit revocation.Acknowledgement of
such is by signature below.I declare that I am the owner,owners legal representative,or the co itractor.I further declare that►am entitled to receive this
permit and to do the work as proposed in the application.I declare that I have obtained the perr iission from all the necessary parties.If permission is
required from any easement holder or any other party in interest regarding this application or th work proposed in the application,I have obtained
permission from them to apply for this permit and conduct the work proposed. The owner or ag nt on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described pri perry and structure for review and inspection.
PROOF OF NTINUATION QF K IS BY MEANS OF A PROGRESS INSPECTION.
X - - � Z�. _ Date:
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THI POINT
Accepted by Planning Pd Ck# Date W u ( Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department
Occ Group-Type Constr.
Planning Department
Environmental Health Department
FEES
Plumbing & Base Fee Site Ins ctioh
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES