HomeMy WebLinkAboutCOM2003-00151 Sign Mounted on Kitsap Physical Therapy - COM Permit / Conditions - 2/12/2004 O C() CO m a 2 �
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MASON COUNTY ie"
BUILDING PERMIT APPLICATION15/
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
APPLICANfTT INFO TION CONTRACTOR INF MATION nn
Owner /�IAV- Contractor Name ,GA*C ) �/ it1 lA.
Mailing,Address 1 Mailin Address
City Kr L,9'.e rc. State 1JA Zip Code ;RTrz_4 City L� State_(g&Zip Code '38 3
Phone( ) Other Ph. ( ) Phone (^� o ) - Other Ph. ("��) S'i�
Lien/Title Holder Contractor Reg. 4P1 /aBH7Exp.
Email Address Email Address c 60-8-1.4 twr
SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic
Connect to Sewer System Name of Sewer System
Well Water System Name of Water System
PARCEL INFORMATION - 12 digit Tax Parcel No. 1� '� `g / U C;p\() Fire District
Legal Description
Site Address (Please include street name, street number and city) .��`�
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No)
Is property located within 200' of saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs
PERMANENT RESIDENCE ❑ SEASONAL RESIDENCE ❑
TYPE OF JOB - New Add Alt Repair Other Use of Building Lp_�
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?(Yes/No) yam_
Describe Work
No. of Bedrooms No. of 8&throoms SQUARE FOOTAGE- Ist4loor 2nd Floor
3rd Floor Loft Basement Deck Other sq..ft.
Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? (Yes/No)
Installer Name Certification No.
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. OWNER/BUILDER ACKNOWLEDGES SUBMISSION OF INACCURATE INFORMATION MAY
RESULT IN A STOP WORK ORDER OR PERMIT REVOCATION.ACKNOWLEDGEMENT OF SUCH IS BY SIGNATURE BELOW:
OWNER AFFIDAVIT-I certify that I am exempt from the require- CONTRACTOR'S AFFIDAVIT- I certify that I am currently regis-
ment of the Contractor Registration Law RCW 18.27 and am aware tered as a contractor in the State of Washington and that I am aware
of the ordinance requirements for which this permit is issued and of the ordinance requireme regulating the work for which this
that all work will be done in conformance therewith. No changes permit is issued and all hall be done in conformance there-
shall be made without first obtaining approval. with. No chan s a without first obtaining approval.
X Date X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Planning Pd Ck#
Date Bld Pd. Reciept No.
F
Building Department
Occ GroupType Constr. rL 9�15�
Planning Department
r.
Environmental Health Department <
Public Works Department
Fire Marshal
Valuation$
y
h
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee Planning Review Fee
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal
77
y r y
TOTAL FEES
MASON COUNTY P - -
BUILDING PERMIT APPLICATION 03IS/ '
426 W. Cedar• P.O. Box 186, Shelton, WA 98584
Shelton (360)427-9670 • Belfair(360) 275-4467 • Elma (360)482-5269
a., On the Web www.co.mason.wa.us
APPLICA jg INFO TION tt CONTRACTOR-INFO MATION
Owner A N Contractor Namet,SC r o.
Mailin =ress-2416oMailinAddressCity ire. State L A Zip Code '•B City I reA A4(A State_(&&Zip Code %3f 3
Phone ( ) Other Ph. ( ) Phone ("tea ) + '. Other Ph. Cyjt MS i�
Lien/Title Holder Contractor Reg. ,4o „_,Gm?f9Exp.
Email Address Email Address csrn �_„ ��ayex.i•aEt ,.N "t
SEPTIC/WATER SYSTEM INFORMATION -Connect to New Septic Existing Septic
Connect to Sewer System Name of Sewer System
Well Water System Name of Water System
PARCEL INFORMATION - 12 digit Tax Parcel No. ! ? . / / C,C t -1 C Z Fire District
Legal Description
Site Address (Please include street name, street number and city)
Directions to site
Will timber be cut and sold in parcel preparation? (Yes/No)
Is property located within 200' of saltwater Lake River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs
I PERMANENT RESIDENCE ❑ SEASONAL RESIDENCE ❑
TYPE OF JOB - New Add Alt Repair Other Use of Building L
r Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?(Yes/No) r;1
Describe Work , e .. . ;
No. of Bedrooms No. of B.M rooms SQUARE FOOTAGE- 1 s loor 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
j Garage Attached Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price$ Replacement Unit? (Yes/No)
Installer Name Certification No.
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
i. INSPECTION OF THIS PROJECT. OWNER/BUILDER ACKNOWLEDGES SUBMISSION OF INACCURATE INFORMATION MAY
RESULT IN A STOP WORK ORDER OR PERMIT REVOCATION.ACKNOWLEDGEMENT OF SUCH IS BY SIGNATURE BELOW:
OWNER AFFIDAVIT- I certify that I am exempt from the require- CONTRACTOR'S AFFIDAVIT - I certify that I am currently regis-
ment of the Contractor Registration Law RCW 18.27 and am aware tered as a contractor in the State of Washington and that I am aware
of the ordinance requirements for which this permit is issued and of the ordinance requirements regulating the work for which this
that all work will be done in conformance therewith. No changes permit is issued and all c� rk hall be done in conformance there-
shall be made without first obtaining approval. with. No chan s$hal�4i ' e without first obtaining approval.
X Date X V 1 Date — -rj
i
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Planning Pd Ck#
Date Bid Pd. Reciept No.
7
Building Department
Occ G roup Type Constr.
Planning Department LG-pb
I! Environmental Health Department
Public Works Department `
Fire Marshal
Valuation$
s
h �-, ,.;' ...,:',, it,,. . : ., �....,, ...
Building Permit Fee Site Inspection
Plan Review Fee EH Review Fee
Plumbing&Base Fee Planning Review Fee
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee State Fee
Violation Fee Pre-Paid at Submittal ( )
`i TOTAL FEES
08i26iO3 TUE 08:30 FAX 3602750036 Kitsap Physical Therapy �002
Manson Sign Company, Inc
25 March 2003
Kitsap Physical Therapy Revised 4111/03
24160 NE St Rt 3
Belfair WA 98528
We propose to fabricate and install one 16 %s"x 11'3"channelwrap display. Cabinets are .050 aluminum
welded and painted. Faces are high impact acrylic with 1"trim cap. Copy applied with 3M Gerber Series
230 translucent vinyl per approved layout and colors. Lighting is with 13mm neon as required. Lighting
and workmanship guaranteed for on year from date of installation.
For a total of $3777.00 plus tax and permits
50%down payment required to begirt all work;balance due upon completion.
Acceptanee of Proposal: The above prices,specifications and cone are satisfactory and are hereby
accepted. You are t the work as specified. Paya=w01 be made,as outlined above.
Customer sis4qel7 - Date of Acceptance
Authorized Signs a Date ofAcceptance
i
C:1 /Conn !State *OCCLUSIONS
t3` h' permits sad foes,hidden eoaditi"L%MOOS rW9 fee,(if required),Federal,state or does!taaaR
Neon illmnlnadon:Electrician must prrnide dedicated ground and t wtW per Article 600 of the Natiotnl Elec;f k Code,paragraph 23,which now requires all transformers to have secondary ground fault protection. This is also a UL
requirement known as UL2161.
Electrkml eircait to sign location by others irrrequired.
` Prevailing wage requirements are not considered as a part of this estimate.
Estimate is valid for 90 days.
All material is guaranteed to be as specified. All work to be completed in a we rkmaniike manner ac�dWg to standard
practices. Any alteration a deviations from the above specifications involving extra costs will be executed upon
only written orders,and will become an extra charge over and above the estimate. Our workers are fully covered
Workman's Compensation lnsuraaoe
by
i
[n aw"dance with State of Washington laws,a Claim of Lien may be filed if
invoia date. A Conditional Liar Release will be issued y payment is not received within 4p dayy pt
upon payment.
Mailing Address: PQ 8*929 0-Silverdale 4 WA 0 98393
Street.Address. 9438 WillapYctte Me►'ic�an 0 Silverdale 0 WA 0 48383
(3�)b13-9$50 0.> c(3 )61•.3-9315
email:gkelstrup�sil`rerlkne
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