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Fail Date Q � m 0 o m co N O n O a 0 Cn 0 3 N (D N (D 0 09/28/2012 16: 52 3604277466 �� 'VMPIC HEATING PAGE 01/01 FORM MUST BE COMPLETED IN INK `��� 0 PERMIT NOj� Id PLEASE PRESS HARD MASON COUNTY PLUMBING2ECHA oI CA ox 8PERMIT PPLICATIONM 6 Shelton (3§0)427-On 0 e$el{air 36OU75-on wa.Elm' (360) 482-5269 APPLtC T FORMATIO r) us CONTRACTOR I RMATt0 Owner 1 ! Company Name Mailin Addres r` Maili Address City, - >Mate _Zip Code City - tat® Zip Code Phone Other Ph Phone Other Ph. lien/Title Holder Contractor Reg., 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. old• 5 - oZ Fire District Legal Description Site Address (Please include street name, street number and city) Directions to site Is property within 200'of Saltwatey Lake River/Cre' Pond Wetland Seasonal Runoff Stream Slopes or Bluff' TYPE OF JOB - New Add Alt Repair Other U of Building Location of Fixtures/Units- 1 st Floor 2nd Floor Basement Gars e Closet PLUMBING FIXTURES (Show Number of each) i MECHANICAL UNITS Type of Fixture No. of Fixtures Fees Fuel Type:Ele G.-- LPC-L_ Natural Gam_ Neat Pump_ Toilets Tvpe of Unit No.of Units Fees Bathroom Sink Furnace Math Tubs Heatpumps Showers Spot Vent Fan Water Heater Propane Tank Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/Pelltttove Dishwasher Kitchen ExhaustHood Dryer Vent Hosebibs Other Other Base Fee Base Fee TOTAL PLUMBING - TOTAL MECHANICAL ---- C7�INER/gUiLDFR Acknowledges submission of inaccurate information may result in a stop rk order or permit revocation.k-knowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the c rWor.1 further declare that I am entitled to receive this limit and to do the work as proposed in the application_t declare that I have obtained the pe ission from all the necessary parties.if permission is required from any easement holder or any older party in interest regarding this permission from them to apply for this permit and conduct the work proposed.The owner or nt on owners application or work proposed in the application,I have obtained behalf,represents that the information provided is accurate and grants employees of Mason County access to the above described arty and structure for review and inspection. FFi00F F CO NUI#TION OF RK iS BY MEANS OF A pF10GRESS INBPECTl01�' - Date: owner/owners Representative/ On raOtOr (indEcat®which one) FOR OFFICIAL USE BEYOND THIS POINT Accepted by: Planning Pd Ck# _Date Bld Pd Receipt Na. DEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ GroU T e Con r_ Plannin De artment Environmental Health Department FEES Plumbing &Base Fee Site Ins a on Mechanical &Base fee UFC Plan iew Fee Wood/Gas/Pellet Stove Fee Other Violation Fee TOTAL FEES