HomeMy WebLinkAboutBLD2003-01405 - BLD Permit / Conditions - 9/30/2003 (2) FORM MUST BE COMPLETED IN INK
PERMIT NO.:
PLEASE PRESS HARD MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION c MV5
426 W.Cedar/P.O.Box 186 Shelton WA 98584
Shelton(360)427-9670 Belfair(360)275-4467'Elma(360)482-5269
APPLICAKIT INFORMATION CONTRACTOR INFORMATION
Owner D N l'] Contractor Name r,6ge.,5LL 0,SAS
Mailing Address % " ,ql i lt)e) o1- ° Mailin Address
City.`NCL T� State&) Zip Code - � City nOSPd / State he Zip Code
Phone(�e) )1/�7- ZOther Ph.�� Ph.(� Other Ph.(pC
Lien/Title Holder IV ON5 Contractor Reg. #
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic -----Connect to Sewer System Name of
Sewer System
PARCEL INFORMATION- 12 digit Tax Parcel No46 �ao 1 -7-2 / 9�91 e / Fire District 1
Legal Description .Cz' Z�,--
Site Address(Please include street namoiqtreet number and city)
Directions to site LJ& U) ' J04 L e /n /l l e)
�//E'kTo 1 &)A
Is your property within 200'of the following: Body of Water(Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream
Slopes or Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures Fees LPG "V/ Natural Gas Heatpump
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers Spot Vent Fan
Water Heater Propane Tank'�,�C, �u
Clothes Washer Gas Outlets
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood
Hosebibs Dryer Vent
Other Other
Base Fee Base Fee -��� • n t i
TOTAL PLUMBING TOTAL MECHANICAL
IL-
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL$VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
a first obtaining approval.
Date X Date
FOR OFFI IAL USE BEYOND THIS POINT
Accepted by Date '� - ubmittal Amount Due �y � Receipt Na° � -'
t)EPAR7MENTAL REVIEW. APPROVED [3ENIEt7:: COts1CJITION C.O[)ES
Building Depp nt �� L1
Occ Grou Type Constr. �O
Planning Department CAL
Other
Other
SEE 5
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES