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Box 186, Shelton,WA 98584 427-9670/1-800-562-5628 #1 Owner Phone#_ 3 Lo - 2 7 - G ya 8 Site Address Fire District# 2. City St Zip Directions to Job Site D / ,E /V AVA A/Ar 44 A r- - /0bA5. - Owner Mailing Address o City r2..^R•^ St �✓a, zip 9B31Z Lien/Title Holder ovsn� Nm�� Address City St Zip t #2 Contractor Name 01.0W C-r Contractor Reg# Address Expiration Date City St Zip Phone# 4 #3 If septic is to ted on project site, include records. Connect t eptic? Public Water Supply Well Conine o Sewer System? Name of System (If re dential, proof of potable water is required) #4 I No. /2 3 4 - So egal Description T�.N 4,4-kIL Tr AC Are 4 4* ,?Ac, A� � 3lz Gs'? #5 Building Square Footage: (existing/proposed) 1st FI / 2nd FI / 3rd FI / Loft / Basement / Deck / #bedrooms / #bathrooms / Garage--JZ,5 0/ Carport / (Circle:Attached o etached?) Other sq.ft. / #6 Use of building t &A r,a 9 A a-- 57's rat 4� Describe work Ll A e. I/i w/ � e►.�+'tit o�G t7ss r] ate- / - 1�sx G'8 soQQ L1 .Dew✓� #7 Type of Job: New_ ^Add Alt Repair Other #8 M/ooms FACTURED HOME INFORMATION M Makd` Model �ECE�V�� LWidth Serial No. SEP 24 1997 # #Bathrooms Type of Heat P $ #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 Se onaI Runoff Other 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 `5 Name of Flanking Street Indicate Directional by (N, S, E, W) Name of Fronting Street in relation to plot plan APPLICANT TO DRAW SITE PLAN,BELOW 0 f MASON BUILD A ING INSPECTOR T 'C CH ANG 5 SU6IECT TO APPROVAL . OAR 7 Rt O ,Jlfo yzq• APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW �w4w ,Zoo'f Te fr.� h Ir1�YlliiiflYlM FII f Y11 Y Itlf Plumbing Fixtures ($3.35 each) Fee Mechanical Fixtures ($6.75 each) No. Toilets CIRC FUEL TYPE: Gas, Electric, Bath Basins Heatpum , Other Bath Tubs No. lilrpqqnr-^, Fees hoovers BTU _Ho Water Htr _ _Laun Washer _ _Sinks _ ns _Floor Drain � _Laundry Basin _ HP _Dishwasher No. Air H ndlin nits _Disposal cfm# _Urinals No. Fire Protection m _Other Auto. Fire Alarm \IV 50.00 Fixed Fire Supp. 50.00 Permit Basic Fee 16. 5 Auto Fire Sprink S 35.00 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 6.75 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 OFTHE 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 OWN X BY DATE a 4 Zi z DATE k DEPARTMENTAL REVIEW FOR OFFICE USE ONLY Approved Cond. Hold Approval Planning: G Environmental Health: Y ID Building Plan Review e i,4 es L s 3S S a 7 FOt)FIJ L AN T C1,77 — vt�r ca-1 G- c- a i.- 14-iz- -e IiS /-t-T7oLG pA . Occupancy Group: Type of Const: � Fire Marshal: Other: Special Conditions: FEES Building Permit Plan Check 2� Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee Sa Other pd rz!�e2 Other ' Building Valuation: TOTAL FEE GARY YANDO,DIRECTOR ' DEPARTMENT OF COMMUNITY DEVELOPMENT p PLANNING-SOLM WASTE-UTILITIES BLDG. I • 411 N.5TM ST. + P,O. BOX 578 tssa.. SHELTON,WA 98584 • (360)427-9670 DISCLAIMER/WAIVER OF COUNTY LIABILITY:PERMITS ON EXISTING LEGAL LOTS OF RECORD, LAND DIVISION APPROVALS,SHORELINE PERMITS,VARIANCES,AND SPECIAL USE PERMITS: The undersigned property owner is aware of the uncertainty regarding Mason County's development regulations created by the Growth Management Hearings Board's Order of September 6, 1996, and in consideration of Mason County's willingness to proceed with processing of applications which might be affected by that Order,the undersigned property owner hereby agrees to waive any lawsuit, action,or claim for damages against Mason County which may arise out of Mason County's actions in acceptance, processing and/or issuance of such permits or approvals (hereinafter"permitting actions"),which damages are attn'lxrtable to the County's decision to take permitting actions despite the risk that changes to the County's development regulations might later make the County's permitting actions invalid. 12305-- SV- 00035 Date (Parcel No. or Legal Description) Property owner's signature (or the County may accept the signifure,of the owner's authorized agent upon proper proof of authorization) ACKNOWLEDGEMENT CERTIFICATE(INDIVIDUAL) STATE OF 614 50 toc- yiu COUNTY OF MQSgj!j On this aceday of Sot , in the year 1917, before me_ Notary Public, personally appeared rl n-t kae personally known to me to be the Arson whose name is subscribed to this instrument, and acknowledged that he/she executed it. WITNESS my hand and official seal. *���Y L ���/• tON Q , For County use only- • / viewed by applicant on �NflTARY (Date} Notary's si re �, S PUBLIC 0 M Co ton Ex it J i�Q Initial: Y P t`IN ft 0•••�'