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Box 186, Shelton, WA 98584 427 9670/1 800 562 5628 �� Q PLEASE PRINT /` / /��/ J #1 -.O��er Hcf-460 L�e, f"ef-k— (� /=/C�'C�S�n�Phone# 1 ��� ���.� d 7• � �ite Address Fire District# U� City StA_Zip Directions to Job Si e c1l rn l Owner Mailing Address E0 2",���� City AQ i v n St JALA _Zip Lien/Title Holder Address - d Cfty St 1/l/ A Zip #2 Contractor Name 661 Contractor Reg#AvrETc+rii c D C Address Expiration Date 3 / 3 0 / 9 P City) e 4�L") St. W /k Zip C c Phone #3 If septic is located on project site, include records. Connect to Septic?__Public Water Supply WelIC' e rn2u fz j � tiw / Connect to Sewer System? Name of System (If residential, proof of potable water is required) # ISarcel No. 122- 32 - - 7009 0 Legal Description #5 Building Square Footage: existin proposed}--_ eNLAA,6-t"(,b- 2CO-r'A fe-Cbo 1st FI /��nd FI / 3rd FI / Loft Basement / Deck / #bedrooms / ,q #bathrooms / Garage /, Carport / (Circle ttache ,or Detached?) Other sq. ft. / #6 Use of building �_I2 1 y l 5�... ,e o o Describe work T T .a~ i v x z.,o s,-,.,. A. zyO s9' #7 Type of Job: New Add X Alt Repair tQ Isi LEI- 'I �y' ((•��. Z-1/0 a? Ls W Lg UU t a i j #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year Make Model FEB 18 1997 Length Width Serial No. # Bedrooms #Bathrooms Type of Heat HEALTH RMA"' C� Purchase Price $ 1F ! L #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 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 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 f`PrT,,lG v f�,f_s�J Z7 C-_4 i,c L� S✓w/ f,..Iy 32/ J 9; O V G.�p� v��c✓ L•o� �A0 APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW Le7' 1-7— Plumbing Fixtures ($3.35 each) Fee Mechanical Fixtures ($6.75 each) No. Toilets CIRCLE FUEL TYPE: Gas, Electric, Bath Basins Heatpump, Other Bath Tubs . Units 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 16.75 _ Auto Fire Sprink Sys 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 16.75 WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COM- 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 WORKFOR 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. 2n Z X OWNERC�� X BY vusE7,4/ Ccw.r T. DATE DATE IAt USE{ iLY AWept+ dy Oates & v; DEPARTMENTAL REVIEW FOR OFFICE USE ONLY F roved Cond. Hold Approval Planning: Environmental Health: Building Plan Review —, ;d e- nnar (Z"cS t onN A-0D M o N, IIZ Occupancy Group: rZ- Type of Const: N/-l�,t Fire Marshal: Other: Special Conditions: FEES �1 2 n 4(0 S� 1 �2--- Building Permit �08. C(�' 5-0 Plan Check 27.2� , =o Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee Other Other -E. _ Building Valuation: /7yC) TOTAL FEE 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 by (N, S, E, W) Name of Flanking Street in relation to plot plan Name of Fronting Street APPLICANT TO DRAW SITE PLAN BELOW C ' I o � e`�{ j . S M*1,CYAC Leo 10 R- APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW I s xVy L..wv�� I.KNE P 14 ,moo GARY YANDO,DIRECTOR SON.STA-P- o A �, DEPARTMENT OF COMMUNITY DEVELOPMENT U o T i PLANNING -SOLID WASTE-UTILITIES N Y y BLDG. I • 411 N. 5TH ST. • P.O. BOX 578 of 1864 �o SHELTON,WA 98584 • (360)427-9670 DISCLAIMER/WAIVER OF COUNTY LIABILITY:PERMITS ON EXISTING LEGAL LOTS OF RECORD, LAND DIVISION APPROVALS,SHORELINE PERMIT'S, 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 B6ard'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 attributable 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. RR of �� sw � Gl� Gf-�acPeV►�W ' 7 71Z 07a s p 0--?Z 3 l Date tParcel No. or Legal Description) Property owner's signature(Notarized) (or the County may accept the signature of the owner's authorized agent upon proper proof of authorization) ACKNOWLEDGEMENT CERTIFICATE(INDIVIDUAL) STATE OF COUNTY OF On this-day off ' in the year JQQJ before me .Y-VI J/L—Notary Public, perso -- n-- ? rsonally known to me to be the person whose name is suJcrilaed tcrtlitsent, and acknowledged that he/she executed it. t WITNESS my hand and offl cial seal. -For County use only- ' Reviewed by applicant on v ay > (Date) o ry's signature - Commission Expires: '2 �] Staff Initial: