HomeMy WebLinkAboutBLD2000-01157 Dock - BLD Permit / Conditions - 8/21/2000 C, o00
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313H0N00
PERMIT NO.: BLD
MASON COUNTY
_ BUILDING PERMIT APPLICATION
//// ���� ..,L ��e la 6,Shelton,WA 98584
l'i`'� g27B'elfair 360 27 46 Elm, 360 482-5269 Seattle 206 464-6968
AP ICANT INFORMATION CONTRACTOR INFORMATION
Owner %c�'.' c, f..� f��`r Contractor Name
t--
Mailing Address Mailing Address ice,
City: State Zip Code _; City Stater Zip Code -
Phone Other Ph.(;, �) <. Ph.( ) Other Ph.(
( "� �� Contractor Reg. # '-
Lien/Title Holder
Address Expiration / /
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. '_ " ' p ;/ _/ Fire District_
Legal Description ,` ° y
Site Address(Please include street name, stre t number and city) ee 9�r
Directions to site —+--
M
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water (Name) 1 Q' t Saltwater
Lake n' River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work I
No. of Bedrooms No. of Bathrooms SQUARE F OTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE 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. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-[certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-1 certify that I am currently registered as a
Contractor Registration Law RCW 18.27 a,9d am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit i 'ISSUO and that all work will be done in requirements regulating the work for which this permit is issued and all work
conforma�ice therh No>chhg sh be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approvaV - 'yLL" first obtaining approval.
f.
f Date
X !.. Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by i , ) Date _,Submittal Amount Due � .; 1 Receipt No
DEPARTMENTAL REVIEW APPROVED DENIED CONDITION CODES;
Building Department �►_Zo� >% t I r✓� L ;
Occ Group —I Type Constr t
Planning Department
Environmental Health Department
Public Works Department
i
Fire'Marshal
Valuation $-,'T 'ji
'FEES
Building Permit Fee Site Inspection
Plan Review Fee r ;6 ; i UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Other
Wood/Gas/Pellet Stove Fee Other
Violation Fee Pre-Paid at Submittal ( )
TOTL A F E ES
'::
PERMIT NO.: BLyD�p�
MASON COUNTY Q IIS 7
BUILDING PERMIT APPLICATION
426 W.Cedar/P.O.Box 186,Shelton,WA 98684
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner i, f °`t �. � , Contractor Name "
Mailing Address f : • <- r" k r , ' Mailing Addresser.
City c E t '.•;1 State .�L 'Zip Code t City y= State ,r Zip Code
Phone(__) + Other Ph.( ) r Ph.(_ _Other Ph.(
Lien/Title Holder Contractor Reg. # °
Address Expiration
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. a ;� °;-;� / Fire District
Legal Description ;
Site Address(Please include'street name, street number and city)
Directions to site 1
Will timber be cut and sold in parcel preparation? (Yes/fro rJ .3I r
Is your property within 200' of the following: Body of Water (Name) p-rrs /ri #I� s Saltwater
Lake x River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
Describe Work 1 , :d , z y,�` .
No. of Bedrooms No. of Bathrooms SQUARE F OTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Deck Other sq. ft.
Garage Attached Detached Carport Attached Detached
MOBILE 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. 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 iyssuq and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith No chang sha be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approvaV, I J� first obtaining approval.
X X Date
a I s z 'h Date l:Y"1
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date '; Submittal Amount Due _ �f Receipt No.
..................................
pPARTMENTAI»R1/I�W APPRQVED DENIED CONDITION CODES
Building Department
Occ Group Type Constr.
Planning Department ► l.�'
L t�U '� 4
Environmental Health Department I /7,,LI
Public Works Department
I
Fit-6-Marshal
Valuation $ �t i
FEE
Building Permit Fee Site Inspection
Plan Review Fee ,4 ? UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Othe — - --
,
Wood/Gas/Pellet Stove Fee Othe
Violation Fee Pre-Paid at Submittal ( )
A ES
TOT FE L
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION
Case No.
Name
�.-, ��It.-ff�ARCEL NUMBER �� ���C ���'� �'� bate
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
Names of Fronting Streets Septic System
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line.
adjacent property line- , I E-adjacent property line
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adjacent property lined 1 I <-adjacent property line
SAMPLE SITE PLAN
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TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.)
SAMPLE TOPOGRAPHY PROFILE
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,.:
MASON COUNTY PROJECT SITE INFORMATION
Case No.
Name
PARCEL NUMBER Date
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
Names of Fronting Streets Septic System
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet ofl adjacent property
t property line
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SAMPLE SITE PLAN
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TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. if possible include height and the
degree of slopes. See sample topography profile.)
SAMPLE TOPOGRAPHY PROFILE
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