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-" � 30
MASON COUNTY PERMIT NO.
DEPARTMENT OF COMMUNITY DEVELOPMENT
t BUILDING•PLANNING. FIRE MARSHAL
»I WWW.CO.MASON.WA.US (360)427-9670 Shelton ext.352
Mason County Bldg, 111,.426 West Cedar Street (360) 275-4467 Selfair ext. 352
PO Box 279,Shelton,WA 98584 (360)482-5269 Elma ext. 352
PLUMBING & MECHANICAL PERMIT APPLICATION
j OWNER I.NI~O.R]VIA TON: _ CONTRACTO INFORMATION:
NAME:_Dn, " N A ME; i• a � _
MAILING A.D RE S: I 1 �_w V7[� MAILING AD RFSS: O �__,.1„a.� — �—
j C1:T1':�Ct � STATE:W c- Z.1P: q 6,5S q CITY: STATE, W o—_—
PI°LONE- gyp. ;! �`� F,�f PHONE: �' -
EMAIL: EMAIL Al pip �Y.1t„tl�" - YY�_
L&I RE " # `��lzt' Eh-/�9/ ES
—� -
PARCEL
INFORMATION-
PARCEL NUMBER (12 DIGIT NUMBER):
f LEGAL DESCRIPTION('4Bpnrl/,4rP,b):
I SITE ADDRESS:-u l UJ 1-1�u.1� t r w y n �" r� CITY:
DIRECTIONS TO SITE ADDRESS:
! 'TWE OF JOB
NEW ADD .ELT REPAIR OTHER USE OF BUILDING
JCATION OFF 1'URES/UNI. S- 1,T FLOOR zND --- ---- --
FLOOR BASEMEN7' GA,R C,F OTHEIR
1 'PLUMBING FIXTURES(SHOW NUMBrR OF EACH) MECHANICAL UNITS
I TY�pe of Fixture NLo, of Fixtures Fees, Fuel Type:Electric LF10 Natural (la5Hear Pump
�
Toilets —�W r e f Utai.t No, of Units Fccs
Q�.
3athroom Sink Furnace
Bath Tubs — _ --_ Heatp-ump
3! shower's s — {� Spot Vent Fan
1 Water Rcatcr _ Propanc Tank
Clothes Washer. ' 0 2Q- Gas Outlets
Kitchen Sinks WooCC/Gas/Pellct Stavc
! Dishwasher Kji�cben'Exhaust Hood
Hoscbibs _ J. C E DA I Dryer Vent
Other —� Other
I "
Base;Fee Base Fee,
!' TOTAL PLUMBING —._ TOTAL:MECHANICAL
OWNER 'BUILDER acknowledges submission of Inaccurate information may result in a Stop work order or permit revocation.
A.rknowledgernent of such is by Signature below. I declare that I am the owner,owners legal representative,or contractor. I further declare
t1.^t I am entitled to receive this permit and 1:0 do the work as proposed,I have obtained permission from all the neees ory parties,including
arty easement holder or parties of Interest regarding this project. The owner or authorized*gent represents that the inf„rmation provided is
,ccurate and grants employees of Mason County access to the above described property and structure(s)for review and Inspection.This
permit/application becomes dull &void If work or authorized construction is not commenced within ISO days or if oonstructicn work is
szjspended for a period of 180 days, PROOF OF CONTINUATION OF WORK IS BY MEANS OF INSPECTION.INACTIVITY OF THIS
t 6 APPLICATION OF 180 DAYS WILL INVALIDATE THE APPLICATION.
L5 -
Signature of Applicant
�`. D6ta
x
_ 0wner1Qwners f gDmie entative o tractor
I Print blame (indicate which One)
BUILDING.DEPARTMENT
PLANNING DEPARTMENT
FTRE MARSHAL
Gas Piping
CONCRETE MANUFACTURED HOME
rQ
C) Interior-Date BY
Footings I Setbacks Ribbons m
T to
0)
CD Date By BY --I
INSULATION Date
0° Foundation Walls 80 1$LAS INSU LATION Set-up
0
Date By Date By bate By z
FRAMING Floors FIRE DEPARTMENT
Date By Date By Date BY
Walls DECKS
PLUMBING Dale By Date By
Groundwork Vault. TANKS
Date BY
Date By Date BY
Attic
Date By OTHER
Date BY DRYWALL Type:
Date By
Water Line Date BY Tyw 03
_U Date, By Int,Swam V611 Date By I—
Date 0
U) MECHANICAL FINAL INSnc CTION K)
CD Fire Seperation C1
CD Dam By Date BY Date f3y/zm 1 CA
E; CD
Pass or Request Inspect. CD
CF)
o Type of I nsp. Fail Date Date Done C 0 By Comments 0
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0
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