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Fail Date Date Done By Comments -4 CD 0 0 0 0 ch -0 CD 3 (D 0 11r''21/2012 13: 43 3604277466 OLYNlPIC HEATING PAGE 01/01 FORM MUST BE COMPLETED IN INK PERMIT NO. PLEASE PRESS HARD WSON COUNTY PLUMBING2MECHr�o1C�A ox�6PERMINTiAPPLICATION Shelton (360)427-K/0•Belfair(360)275-4467• Ek a(360) 482-5269 .m the web www.co,mason.wa.0 F LICANT INFORMATION CONTRACTO INFORMATIONer Company Nam6 n Address_ Mailin Addres$ tate _Zip Coe City a � State- N — Zip Code Phone'�t,'c�-� Xu—f30 Other Ph. Phone c� <b to �u - Other Ph. Lien/Title Holder — Contractor Reg. Exp. E mail address E Mail Address es -C nQ--A - Drivers Lic.# DOB Drivers Lic.# DOB SEPTIC INFORMATION - Connect to New Septic— Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION - 12 Digit Parcel No. 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 - - Wetiand ---Seasonal Runoff Stream Slopes or Bluffs > 15% TYPE OF JOB - New Add Alt Repair Other 11 e of Building Location of Fixtures/Units- 1st Floor 2nd Floor Easement Gara g� Closet PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS jype of Fixture No. of Fixtures Fees Fuel Type:EiectriG— LPC­ Naturai Gas_ Meat Pump_ Toilets Type of Unit No.of Units Fees Bathroom Sink Furnace j Bath Tubs Heatpumps Showers Spot Vent Fan, Water Heater Propane Tank' Clothes Washer Gas Outlets Kithen Sinks Wood/Gas/PelletStove Dishwasher Kitchen Exhaust Hood Hosebibs Dryer Vent Other _ _ Other Base Fee — Base Fee TOTAL PLUMBING^ TOTAL MECHANICAL OWNER/BULDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of Such is by signature below.I declare that tam the owner,owners legal representative,or the contractor_i further declare 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 required from any easement holder or any other party in interest regarding this application or the work proposed in the application,I have obtained '.perrission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information srovided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection. >PROOF F NTINUATION OF WO IS BY MEANS OF A PROGReSS INSPECTION, X Date: k-ao Ownerl ers Representative/Co n Cate which one) FOR OFFICIAL USE BEYOND TH�1113 POINT Accepted by: Planning Pd Ck#_. __ __ Date,_ Bid Pd Receipt No. IDEPARTMENTAL REVIEW APPROVED DENIED NOTES Building Department Occ,Group.Type Cons r Planning Department environmental Health Department FEES Plumbing& Base Fee Site Ins ection JMechanical & Base fee UFC Plan Review Fee lWood/Gas/Pellet Stove Fee Other ("i�Violation Fee TOTAL FEES