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CONCRETE MECHANICAL
Footings-Setback MOBILE HOME
date by Ribbons
date by Gas Piping date
Foundation-Walls b
date by date b Set Up
BG/SLAB Insulation INSULATION date by
date b moors Final
FRAMING date date by date by
date by Walls FIRE DEPT.
PLUMBING date by date by
Groundwork Attic OTHER
date py date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by
date by
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CONCRETE MECHANICAL
Footings-Setback MOBILE HOME
date by
date by Ribbons
Gas Piping date
Foundation Walls b
date . by date by Set Up
BG/SLAB Insulation INSULATION date by
date by Floors Final
FRAMING date by date by
date by Walls FIRE DEPT.
PLUMBING date by date by
Groundwork Attic OTHER
date b date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date
by
PERMIT NO'�i� 0 l
FORM MUST BE COMPLETED IN INK COUNTY
PLEASE PRESS HARD MASON
PLUMBING/MECHANICAL PERMIT 4PPLICATION
426 W.Cedar/P.O.Box 186,Shelton,
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-526 Seattle 206 464-6968
rMailin6-Tddress
PLICA T INFORMATION CONTRACTORNF RMATION
Contractor Nam Eir t?I.0 .
ner � Mailing Addres �- ���
' �' t,d�( � Cit State�, Zip Codey �'� ��� State� Zip Code%— y -,t Other Ph.L�
(�)t/�a. -5i � Other Ph. Ph. t )
Phone �� �-� " (--� Contractor Req ffn'��1��
Lien/Title Holder Expiration
Address
Se tic Connect to Sewer System Name of
SEPTIC INFORMATION-Connect to New Septic Existing p
Sewer System
Fire District
PARCEL INFORMATION
digit Tax Parcel No. �= 1,
Legal Description n n C_iA
Site Address(Please include street name, street number and city}
Directions to site
_Saltwater
Is your property within 200' of the following: Body of Water(Name) Stream Slopes or
Lake River/Creek Pond
Wetland Seasonal Runoff_
Bluffs
Other Use f Building s ��'
TYPE OF JO New Add Alt�_Repair Basement Garage Closet__
Location of Fixtures/Units 1st Floor
2nd Floor_
rF
AL UNITS Fuel Type: Electric
PLUMBING FIXTURES(Show Number of each) Fees Natural Gas id Heatpump Fees
Type of Fixture No. of Fixtures it No. of Units
Toilets — s
Bath Basins
Bath Tubs — Vent Fan
Showers Propane Tank
Water Heater — Gas Outl s
Laundry Wsher Wood/G llet Stove
Sinks Direct ent? C3 ✓�.l �c
Dishwasher Other
Other Other
Other Base Fee _
Base Fee TOTAL MECHANICAL
TOTAL PLUMBING
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPEN ANG ON THE TYPE OF FIXTURE/UNIT.
NCED WITHIN 180 DAYS OR IF
NOT CO
IF
FX —
: THIS PERMIT BECOMES NULL&VOID IF WORK OR OR ABANDONED FOR A PERIOD OF CONSTRUCTION1 0 DAY AT ANY TIME AFTIERETHE WORK IS COMMENCED.ED.
IZED IS
the
RUCTION WORK IS SUSPENDEDowner the
OF t✓ONTINUATION OF WORK ran employe
es of MaOF A oonRCounty access to thebove described ibed property and trulctures for reviewts tand
tion provided is accurate and g
ion of this project. Acknowledgment of such is by signature below:
y that I am
istered as a
AFFIDAVIT-I certify that I am exempt and am aware of the ordinance the CONTRACT
m t State o Washington'fand that am awarle of9he ordinance
tor Registration Law RCW 18.2
II be made without first obtaining shall be done conformance therewith. No changes shall be made without
ments for which this permit is issued and that all work will be done in requirements gulating the work for which this permit is issued and a wor
ance therewith. No changes sh first o taining pproval.
l
Date
X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by ____ _
Submittal Amount Due Receipt No�—
Date__—Submittal
; CJEfJIT3.
"'. GD
AFpRpVED t�[il'ff4'3N Gt)DT^5
Budding Department L4 9
Occ Grou Type Constr.
Planning Department
Other
Ot
her er
site ins
pection
Permit Fee
UFC Plan Revie Fee
Plan Review Fee
Other
Plumbing&Base Fee
Other
Mechanical&Base Fee pre-Paid at Sub ittall
Wood/Gas/Pellet Stove Fee
TOTAL FEES
Violation Fee
MIS
MASON COUNTY
MISCELLANEOUS PERMIT PPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 9E1584. 427-9670
PLEASE PRINT
p,Q el�,D 13�'�c9t,�,-c�
Phone# o? ' Fire District#�_
#1 Owner
Site Address C O City
Mail Address
St Zip
City
Applicant "J&Z A S 4 A�2` Phone #
Applicant Address
St Zip
City
Directions to Site: �-
A
#2 Parcel No. `[ 1 - S7�
Legal Description 0\ay
#3 Indicate by circling the applicable source if any water is on or adjacert to the property site:
saltwater lake river creek stream pond wetland seasonal run ff marsh other
#4 Project Start Date
Project C �pletion Date
Use of Buildiing1 scribe proposed construction
V-)w v 0 o.
'Depending upon the type of permit,a floor plan and plot plan may be required.
'This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT CONTR 4C r1JL IV-In
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON-
MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE96UT6 O)FNVASHINGTON AND I AM
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWAREF E ORDINANCE T EQPUIR I I ISSUED AND
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING TH NCE THERE-
IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL W R lk�A� ROUT FIRST
FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. O �t"""��kkkkllllAAAA
WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILD- OBTAIN NG APPROVAL FROM THE BUILDING DEPART
G DEPARTMENT. MENT.
OWNER�;✓ " "3, ''' `s . '� X BY
DATE /--S�' y'S
DATE � �
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL,,.USE ONLY:Accepted by: Date.
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP. HOLD
Building
Fire Marshal
Other
Special Conditions Fees
Permit Fee $
Plan Check
Other
Other
State Building Fee 5 C)
TOTAL DUE