HomeMy WebLinkAboutBLD2012-00253 - BLD Permit / Conditions - 4/24/2012 r
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MASON COUNTY PERMIT NO. GD12
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar•P.O. Box 186, Shelton, WA 98584
Shelton (360)427-9670•Belfair(360)275-4467•Elma(360)482-5269
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner_�Z�f" ,� - Company Name, f,
M i incLAddress �t,m;,� ailing Address -
city �/i /4Zr, State Zip Code�'� "� / City State ' ' Zip Code
Phone _�I�&, q'Lq- )2 � Other Ph. Phone �3 12796, 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 Septic Connect to Sewer System
Name of Sewer System
PARCEL INFORMATION- 12 Digit Parcel No v/v 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
Wetland Seasonal Runoff Stream Slopes or Bluffs 1 15%
TYPE OF JOB -New 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—LPG—Natural Gas—Heat Pump_
Toilets jype of Unit No.
Fees
Bathroom Sink Furnace
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/BUILDER 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 I am 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
permission from them to apply for this permit and conduct the work proposed. The owner or agent on owners behalf,represents that the information
provided is accurate and grants employees of Mason County access to the above described property and structure for review and inspection.
PROOF OF,CONIINUATION CORK IS BY MEANS OF A PROGRESS INSPECTION.
X Date:
Owner/Olw4s Representati /Co tractor (iridica -h one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bid Pd Receipt No.
DEPARTMENTALREVIEW APPROVED DENIED NOTES
Building Department
Occ Group-Type Constr.
Planning Department
Environmental Health Department
FEES
Plumbing& Base Fee Site Inspection
Mechanical & Base fee UFC Plan Review Fee
Wood/Gas/Pellet Stove Fee Other
Violation Fee TOTAL FEES
Gas Piping >
o CONCRETE MANUFACTURED HOME z
(D Inletiot-Date By 0
Footings I Setbacks Exterio(-Date By Ribbons X
0 M
(D Dato By Date BY
INSULATION
W Found-ation Walls BG ISLAS INSULATION Set-up M
Date By Date By Date By 0
FRAMING Floors FIRE DEPARTMENT M
X
Date ByDate By Date BY
Walls DECKS
PLUMBING Date BY Date By
Groundwork Vault TANKS
Date By Date By Date BY
Atfle
D.W.V Date By OTHER
Date By DRYWALL Type:
Date By
Water Line Date BY Type: 03
-0 Date By Int.Brace Wal I Date BY
(D e By
W
(n MECHANICAL Dot
CD FINAL INSPECTION vN
Fire$operation
(D
Date By Date Ry Crate f3y
O
Pass or Request Inspect.
Type of I nsp Fail Date Date Done By Comments CA CD CA)
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