HomeMy WebLinkAboutBLD96-0455 Cancelled Change of Use - BLD Application - 4/4/1996 Permit No.
APR t MASON COUNTY
BUILDING PERMIT APPLICATION
496 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 Owner keY% i 114a.rep # 1'%0 A 75 60!50
Site Address-4-1 3'fl Atka Fire District#
City n ! St zip
Directions to Job Site 3 U� -3
QrGTpY S e. A de—,e,1574' -
Owner Mailing Address Is AaAd O d
City ;ew St Q-- Zip 8
Lien/Title Holder AZ
Address O II D-
Clty St Zip
#2 Contractor Name ZLtractor Reg#
Address Expiration Date
City t Phone#
#3 If septic is located on project site, inc de reco
Connect to Septic? Public Wat upply Well
Connect to Sewer System? Name Sys
(If residential, proof of potable water is require
#4 Parcel No. - Z �66
Legal Description tea* &,4�rn'1 qk`E M• 1 +- aT-f
SE t U tom. E e,{ $mac.. 31 2�? .., 1 �� �U �'1•� iv�9yta
#5 Build' gfSquar� Fo to : (existing/p pAed) ,m0
1st FI / 1 J% 2nd FI / 3rd FI
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other sq.ft. /
#6 Use f uilding Describe work
-Floor a/A
#7 Type of Job: New Add Alt Repair Other
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#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year Make Model
Length Width Serial No.
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#Bedrooms #Bathrooms Type of Heat
Purchase Price$
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#9 Indicate by circling the applicable source if any water is on or adjacent to ub'ect property:
�-Sea�sonAN4��noOtherRiver Pond Creek Stream Wetland Lake Marsh Saltw
6 '
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Driveways
Water Lines Shorelines
Drainage Plan Topography
Septic Systems Wells
Proposed Improvements Easements Indicate Directional b N, S,
Name of Flanking Street in relation t Ian y lot ' E, W)
Name of Fronting Street p p
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 egghl Fee Mechanical Fixtures ($6 each)
No._Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
_Bath Tubs No. Unk Fees
_Showers Furn 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. Fire Protection Systems
_Other _ Auto. Fire Alarm Sys 50.00
Fixed Fire Supp. Sys 50.00
Permit Basic Fee 15.00 _ Auto Fire Sprink Sys 25.00
TOTAL PLUMBING $ No. Other
Gas Outlets
Wood, Gas, Pellet Stove
NOTICE: THIS PERMIT BECOMES NULL AND VOID IF
WORK OR CONSTRUCTION AUTHORIZED IS NOT COM-
MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee 15.00
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD
OF 180 DAYS AT ANY TIME AFTER WORK IS COM- TOTAL MECHANICAL $
MENCED. PROOF OF CONTINUATION OF WORK IS BY
MEANS OF A PROGRESS INSPECTION.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I 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 AM AWARE OF THE ORDINANCE REQUIREMENTS REGU-
ORDINANCE REQUIREMENTS FOR WHICH THIS PER- LATING THE WORK FOR WHICH THE PERMIT IS ISSUED
MIT IS ISSUED AND THAT ALL WORK DONE WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE
CONFORMANCE THEREWITH.NO CHANGES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT
MADE WITHOUT FIRST OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTMENT.
X OWNER X BY
DATE
DATE
FCa ......... 1Sf ONLY Accepted!byk ` Ot •
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning: 1zNl96
Environmental Health:
Building Plan Review
�2�6
Occupancy Group:f 2 m Type of Const:
J
Fire Marshal:
Other:
FEES
Special Conditions:
Building Permit kq ro`�9
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee �a
Other
Other
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Building Valuation: &b !Zo TOTAL FEE
1
Page No. 1 FEES FOR CASE NO.: BLD96-0455
RON SAGERSON
E16371 STATE ROUTE 3 ALLYN
(This is NOT a receipt)
12/07/99
Case Fee Fee Account Fee Amount Receipt Check Date Rcd
# Description Type Number Amount Paid # # Paid By
---------- -------------------- ---- ----------------- --------- --------- -------- ------ -------- ---
BLD96-0455 Building permit....* PRMT 322.10 145.50 0.00
BLD96-0455 Commercial plan ck PLCC 345.83 94 0.00
BLD96-0455 Building State Fee STFE 386.00.05 4.50 0.00
Total fees:.........$ 244.57 /,
- Payments:.........$ 0.00 �l/�
Balance due:........$ 244.57 ��`
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