HomeMy WebLinkAboutMIS96-00824 Cancelled Propane - MIS Application - 5/11/1997 Permit No.
�. MASON COUNTY rmq(0-6j@q
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
PLEASE PRINT
#1 Owner .0-.c- v�, �� Phone#
Site Address
City < L Lo St 1.y t3 Zip `76S
Directions to Job Site
Owner Mailing Address
City St Zip
Lien/Title Holder
Address
City St Zip
#2 Contractor Name Wit_6_Ajoa'a Contractor Reg. #
Address Expiration date
City St Zip Phone
#3 Parcel No. I Con rQ LI 1
Legal Description C'� -
#4 Use of building Describe work
#5 Type of Job: New Add Alt Repair
Plumbing Fixtures ($3.25 each Fee Mechanical Fixtures ($6.50 eachl
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
_Bath Tubs No. Units Fees
Showers Fu rn BTU
_Hot Water Htr _ Heatpumps
_Laundry Washer _ Vent Systems
_Sinks _ Spot Vent Fans
_Floor Drains No. Boilers/Compressors
_Laundry Basins _ HP
_Dishwasher No. Air Handling Units
_Disposal _ cfm#
Urinals No. Other
_Other _ Gas Outlets
_ Wood, Gas, Pellet Stove 32.00
Permit Basic Fee 16.25 —Mnl(- 1113u—
TOTAL PLUMBING $ ka c (V,51
Permit Basic Fee 16.25
TOTAL MECHANICAL $
No Basic Fee for Wood, Gas, Pellet Sto
e,
NOTICE: This permit becomes null and void if work or construction authorized is not commenced
within 180 days or if construction or work is suspended or abandoned for a period of 180 days at any
time after work is commenced. Proof of continuation of work is by means of a progress inspection.
NOTE: If this permit application includes the placement of a fuel tank, heat pump or other unit to be located
outside of the existing structures, a plot plan MUST be submitted as required below:
Show following on the site plan below: Lot Dimensions, Existing Structures, Structure Setbacks, Water Lines, Septic Systems, F
Flood Zones, Wells, Shorelines, Easements, Name of Flanking & Fronting Streets. Indicate directional by N, S, E, W, etc.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRAC-
THE CONTRACTORS REGISTRATION LAW RCW 18.27,AND AM TOR IN THE STATE OF WASHINGTON AND I AM AWARE OF THE
AWAREOFTHE MASON COUNTYORDINANCE REQUIREMENTS ORDINANCE REQUIREMENTS REGULATING THE WORK FOR
FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WORK WHICH THE PERMIT IS ISSUED AND ALL WORK DONE WILL BE IN
DONE WILL BE IN CONFORMANCE THEREWITH. NO CHANGES CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE
SHALLBE MADEWITHOUT FIRSTOBTAINING APPROVAL FROM WITHOUT FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. �J DEPARTMENT.
X OWNER?C _1_A��. X BY
DATE I / / DATE
Return permit to: Department of General Services
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 . 427-9670/1-800-562-5628
FOR OFFICIAL USE ONLY: Accepted by: Date:
Receipt No. Referred To
DEPARTMENTAL REVIEW Proposal Proposal
FOR OFFICIAL USE ONLY Approved Denied
Planning:
Building:
Fire Marshal: