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Box 186, Shelton, WA 98584 427 9670/1-800-562-5628 b�lj c�P #1 l7 'hone#27s d.�7c� A:i Address Fire District# ityP St ZIP Z Directions to Job Site 6 c s h� ( �v44 Owner Mailin Address City St Zip Lien/Title Holder Address City —Si a ZIP #2 Contractor Name �Z-� �`2� `r'aS Contractor Reg Address �. Expiration Dated f City St Zip _Phone# !%2-& -24f/ 1 ` #3 If septic is located on project site, Include records. Connect to Septic? Public Water Supply Well > Connect to Sewer System? Name of System rl (If residential,proof of potable water is required) 4A - 00o 4- 1 . .. _. be 'an '77� J--t;f ofi YS�Q tr T #5 Building Square ootage: (existing/proposed) 1st FI / 2nd FI •/ 3rd FI / Loft / Basement / Deck 1 #.bedrooms / #bathrooms / Garage / Carport / (Circle:Attached or Detached?) Other sq.ft. / -t' #6 Use of building ,4o rS e, Fpoirn Describe work #7 Type of Job:New _Add Alt Repair Other i #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year Make Model I Length Width Serial No. #Bedrooms #Bathrooms Type of Heat Purchase Price$ #9 Indicate by circling the applicable source if any water is on or adjacent to subject property: River Pond Creek Stream Wetland Lake Marsh Saltwater Seasonal Runoff -Other Show Bring on the wits pleat ZOres .. Lot Dimensions Ewsdng� eht�e°s �ertees StructureS acks�f., :y Driveways Water Unes - ` Shoff Drainage Plan Topography Iftkapoems Web, _ .._._- Easements ✓� rQ�l t 1t1re Direcxional by (N, t t in relation to pW plan Zj Af . .SOW tVe a Q` D � rya A1)4o ���, t•e. APPLJCANT TO DRAYV fi -_ rr Plumbing Fixtures($3 each) egg Y AAechar�ic1 Fixtures($6 each) No. Toilets CIRCLE FUEL TYPE: Gas, Electric, ,Bath Basins H tpump,Other ____Bath Tubs Sink Em i wers Furn BTU Hot ater Htr Heatpumps Lau ry Washer Vent Systems in Spot Vent Fans loor Drains Na, Boilers/Comnresson; Laundry Basins HP Dishwasher Disposal cfm# 14004 Urinal Na s Other Au . Fire Alarm Sys 50•� axed Fire Supp. Sys 50.00 Permit Basic Fee 15A0 Auto Fire Sprink Sys 25.00 1 � TOTAL PLUMBING N2, Ql1@L Gas Outlets Wood, Gas, Pellet Stove NOTit' TIOS PERNT II ILL AND VOID IF WIC OR AUT_OR"DI 3 NI T CO$4- MEMM VATHM 180 HAYS OR IF CONS 1RUCTION OR Per it Basic Fee 15.00 WORK 1113 SUSPENDED-CIR ASAWW A PERIOD OF 18 -DAYS AT /WY-TW-- -WORK IS COM- TOTAL MECHANICAL $ 1l d" IS BY OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT I CERTIFY THAT 1 AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT 1 AM A CURRENTLY REGISTERED MENTS OF THE CONTRACTORS REGISTRATION LAW CONTRACTOR IN THE STATE OF WASHINGTON AND I RCW 18.27,AND AM AWARE OF THE MASON COUNTY AMAWAREOFTHEORDINANCERfXXAREMIENTSREGU- ORDNANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICHTHE PERMITmISSi1ED, MIT IS ISSUED AND THAT ALL WORK DONEPWILL BE IN AND ALL WORK DONE WILL BE IN OONFORMIANCE CONFORMANCE THEREWITH:NO CHANGES SHALL BE THEREWITH.NO CHANGES SHALLBE MADE.W1171HOUT MADE WITHOUT FIRS OBTAINING APPROVAL OM FIRST OBTAINING APPROVAL FROM THE BUILDING! THE BUILDINGAPAFfTMENT. DEPARTMENT. X OWNER X BY l DATE DATE _ 4 DEPARTMENTAL REVIEW OFFICE USE ONLY AWoved Coid HoW AWMW Planning. Environmental Health: �f�ly-tiS Building Plan Review Occupancy Group: Type of Cdnst: Fire Marshal: Other: .FEES Special Conditions: Building Permit Plan Check 3 Plumbing Fee R Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee I _ ' iOther Otter Building Valuation: g�a�n$�' TOTAL FEE t