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HomeMy WebLinkAboutBLD2000-00145 CANCELLED Remodel - BLD Application - 2/12/2000 PERMIT NO.: BLD MASON COUNTY BUILDING PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 l Shelton 360 427-9670 Belfair 360 275-t467 Elma 360 482-6269 Seattle 206 64-6968 - APPLIr,ANT INFORMATION CONTRACTOR NFORMATI N -- Own erC 4L ; tt-D'13 Contractor Na Mailing Address • -r 0 E Mailing Address 5 City`t, . � State V Zip Code." ,,'b s� City _ � State Zip Code � � Phone h ' QQ Other Ph.( Ph. Z Other Ph. Lien/Title Holder Contractor Re # 0i-t h.' Address Expiration � 77 1 / 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 igit J�ax Parcel No. =a Fire District L�rections Description 4. Sddress(Please include street name, street number and ci to site t ° .J r Will timber be cLXand sold in parcel preparat n? (Yes/No) Is your property within 200' of the following: Body of Water(Name) Saltwater Lake River/Creek Pond Wetland Seasonal n trea 1001 lopes or Bluffs �1 j TYPE OF JOB New 4p�Add Y Alt Repair O er Use o Describe Work No. of Bedrooms "o. ol`" athrooms�_S Q U A SOO AGE-1st F or 2nd Floor 3rd Floor Loft Basement Z_ Ot Garage Attached etached Ca ort A d Detached i t MOBILE HOME INFORMATION-Make Mod Model Year Length Width Serial No. No. of Bedrooms No. of Bathrooms Type of Heat Purchase Price $ Replacement Unit ?(Yes/No) i - Installer Name z zcertification No. ! NOTICE: THIS PERMIT BECOMES NULL VOID WO OR CO TRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF CONSTRUCTION WORK IS SUSPENDED OR ND D FOR ERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. PROOF OF CONTINUATION OF WORK IS BY MEA OF A PR RESS INSPECTION. The owner or agent on owner's behalf,represents that the information provided is accurate and grants employees of M on County access to the above described property and structures for review and inspection of this project. Acknowledgment of such is by s- nature below: OWNER AFFIDAVIT-[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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance tberewith. No changes shall be made without a roval first obtaining approval. I Date�7d cUi XL,tf °' . � Dated- 1 1A, � u? FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. ..... . DtwPARTVtNTAa..RV3M _. APPRO�fED D;�MER C...C3(VDITII C+CCES; � Building Department Occ Group Type Constr. Planning Department Environmental Health Department Public Works Department I Fire Marshal Valuation $ . ....................................................:::. . . ::::::::::::::::::::::::::::::::.::::::.:::::.::::.::,:::::::::::::::::::::::;;;;:<:::<.;:<.>:.>;:.;:.;:.;::.;;:;:.;::.;;;:.;;::::<::<.:<:.::.::.:::... Building Permit Fee Site Inspection Plan Review Fee 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 ( ) >.;<:; :::::::::::;.<.::::.::..... • ,�:• >.f:>: v: :: TOTAL FEES ,airi:�<$.:.:t36,�•:•, wa, '�' •u;.iiorr`' Rot %•sk%i�;r.'t>£t`k•'^ w,•w ye• .`•�.t�z .�'y"�'�:rx•, i PERMIT NO.: BLOC MASON COUNTY BUILDING PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98684 �2 Shelton 360 427-9670 Belfair 360 275�467 Elma 360 482-5269 Seattle 206 464-6968 r,-` AFPLI NT INFO MATION CONTRACTOR NFO MATT N �3 ... _f)6`v&, Owner Sc.+-� ��Sb"� Contractor Na Maili g A dress Mailing Ad ss City r State Zip Code a 0 City State Zip Code Phane 3(�0 b40 Other Ph.(� Ph. (o Other Ph. 00 —0 Lien/Title Holder Contractor Re # 01�5� 1 Address Expiration/ / J SEPTIC ER SYSTEM INFORMATION-Connect to New Septic Existin Septic Connect to Sewer System Name of Sewer System WeIIWater System Name of Water System PARCEL INFORMATION-12 igit ax Parcel No. 'L ZZ 1 k / 5 0 ID 1 Fire District Legal Description Lhr- Site Address(Please include street name, street n mber and city) �p� 1(� t `�i � Directions to site 1 L- w. Ex C Will timber be cu and sold iri parcel preparat n? (Yes/No) j Is your property within 200' of the following.- Body of Water(Name) ! 9�) L.�4�4,!�-' Saltwater ✓ Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs i TYPE OF JOB New Add Alt Repair Other Use of Building i QFnJC.L Describe Work '(�4.�oR -f4m.Rwv )-f, ` R' u' Lf20 `*_ lez No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floo 3rd Floor Loft Basement Deck L'Zq Other Sq. 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) f a Installer Name Certification No. 'i NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF 4{I' CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED. f 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: i i 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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance with. No changes shall be made without ap roval. first obtain ng appr val. Date )�1,7000 X Datezl I ub FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. I DEPARTMENTAL REVIEW APPROVEp D�MIwD Cf�NI�ITI4N eC►;dES ; Building Department Occ Group Type Constr. Planning Department fEnvironmental Health Department Public Works Department f i Fire Marshal Valuation $ I ........ 4 I ?> <: .... .... Building Permit Fee Site Inspection �D Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee '` Public Works Review Fee Mechanical & Base Fee Other Wood/Gas/Pellet Stove Fee Other i Violation Fee Pre-Paid at Submittal ( ) ?+ ��«<>r= i<;�x«:':�:+•• .�>• iY.an, is����..«� >`�<x:���•f< t . . TOTAL FEES ;':tt:{;:;ii}:j{jry irr;.�;:b:;{%?x•,'{i;;:•{}.: p{>5,:, •?;:?., ,",:W.'�,':{rikx`7.7+; .',:•'y':,:•+,•.'y"• y,,hrjv:^jn';:•ii;i'r,'+++{+i ii i':'Y•ry r:;:.;• n}.•.:;..•::.;.iv::i:'b::•:: 2•}k.�G:•:•?.0h::,r,•4.•.U.O}:�+iW •M.•.{-0:{{3:.•!.:?.•t}G:?•:i6:•:{+I{,•{�vi+•ii�:^}%{•:is?v:•;: PERMIT NO.: 13L0a"-- &1q5 MASON COUNTY -zj 6 BUILDING PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-6269 Seattle 206 464-6968 7 APPLICANT INFO MATION CONTRACTOR INFORMATION ;'t "._. ..: I• , ;�'. —• Owner`:ij­.)(t w... y, s { , ;r, Contractor Na MailingAddress x Mailing,Address ��` ►�c 9. `� City State Zip Code : s-. City ' r Stated Zip Code i Phone Other Ph.( Ph. 6 'J'42 Other Ph. Q Lien/Title Holder Contractor Req. # + ' r � h,,` ,G t! t♦ I� ' Address Expiration SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic •al'' Connect to Sewer System Name of Sewer System Well,.l_Water System Name of Water System PARCEL INFORMATION-12 digit Tax Parcel No. Z? ;7 Z � t / i / '' : ! Fire District Legal Description Site Address(Please include street name, street number and city) Directions to site Will timber— cuf and sold in parcel preparation? (Yes/No) •. Is your property within 200' of the following: Body of Water(Name) '4~", ; 5. + t* ; Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add Alt Repair Other Use of Building ' Describe WorkIlk No. of Bedrooms]"No. of Bathrooms SQUARE FOOTAGE-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. d' 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 Awl 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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without approval. first obtaining approval. Date.- X Date FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. .. .......LPARTMEI7A>, RIM171W APPROVED DNIp CNIjITI£)N CC?pS Building Department Occ Group Type Constr. Planning Department Environmental Health Department •� C 3 o 20 Public Works Department I Fire Marshal Valuation $ .....................................................:...::......::::. ::::::::.::.::: . :::::::::::::::::::::::::.:::::.::::::::::::::::::.:::.:::::.::.::.::::::::::::::::::.;::.;::«.::.: «<.......;:.: Building Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing & Base Fee Public Works Review Fee Mechanical & Base Fee 'ell CAL 4--e� Wood/Gas/Pellet Stove Fee Other Violation Fee Pre-Paid at Submittal ( ) 8 4 5:.'•: ':'ri:::^;'i'^;`..: ',u:�.�•.•."n'•v i:'''•w:'y'w:ij<w'i:"•.; :;.:,;{{:..�: G::: oxzs. ::::::<;::;>:::. TOTAL FEES {{%%w:'{}">r."}..�aa.:.:,}wag.•'{t{K> ''�Y++ `.^ r.��{:ie�r''r}:{:}.yp:•:}•.,i,::•: •.•. ....:i',:v,:;8,}}i..rn^}:4,:•h#+i: •+•� P.M. 7 •. ../.{:J {:};.}:Y.•:•n}i:^�:'ti:<):"iY::::•:? i�i\Litsi:;i,::•:•:•,:•:C:{•h'Otr::.}ii}Y.{ii{+.•: :{$:2+ ..:} .y •}:YY. :}.{IX?•M�i\'Ci:•}:{{•}:4•>:i:•}}r,•i} w ... ., i«�.`r+4lavWu.MYespsmw+ww�w`•`..swrwwry...•:«rn+..wexwn.w.+ FORM MUST BE COMPLETED IN INK PLEASEVRESS HARD MASON COUNTY PROJECT SITE INFORMATION Case No. _ Name t�_ �+ �-�j L� U r � t, �� PARCEL NUMBERZZZ// SO 90V// Date �n /$r C>l SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan Lot Dimensions Fences AJ JExisting 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 ad' rt ,Ii adjacent property line- i , � � , < c t prZip€C'OVIN PA VA80,14 BUILDM4 AOSPECI o h, rty - -I =5ES8U&TCT%APPFW1J;1 4�- 5 CHANGES i SUBMIT CHAN„ES FOR APPRO AL 1 PRIOR TO PERFORA.41^4G WORK I � I 1 I I �I I ib PLANT MUSTBON TH9 JOB SITE .3 ; FOR INSP CTION, adjacent ro ert lined �-� �`� l ' Fad'acent roe line SAMPLE SITE PLAN adjacent property lined D 310� 30 Fadjacent property line 1�`SCRVE ti HOM tr C2eeK , n I I GadtN I F #0 I Prlo Pos[D so pt:c ---'►� I. 1 14— 6 fit -- ISO I VAC.AKiT 'F c„�rtAr,� 30 P0.nPosCD TA =LLLfuJiAL SO• 1 I 1 , e o --�1 1 1 ' /00" I I I i I I L.�.GLL I adjacent property lined f adjacent properl[y property line 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 dlSta"C-AL to � I ruttL,�Y� slops o¢ ,e .. I �j Signature Date L// R r � pi OM T l { I f w w r P c 3 � a � � e I• R� Z ` f 3 4L I > r 5�8-ot s + A 0 • ' W s , �► i� � > >y L 2 14 moo— , i CL of c f L , •r N 4 r- tA wl x � j t c AA _ �, •� ' tj 16 ,�. ,� V4 FORM MUST BE COMPLETED IN INK PERMIT NO.: PLEASE PRESS HARD MASON BOUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 27-9670 Belfair 60 275-4467 Ehma 60 2-5269 Seattle 206 64-6968 APPLICANT INFORM TION ti CONTRACTOR INFOqVATI Owner t>Ov Ck— ^a ZO e Contractor Name MS Maili g dress c/s-oF Mailin Ad ss City vJS� Stat Zip Code City State Zip Code Phone %V Other Ph.( Ph. O her Ph. Lien/Title Holder Contractor Rey.# L L L O J Address Expiration / / 6C7 SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION-12 digit Tax Parcel o. 2:Z /SO / Cl (Do l I Fire District Legal Description S b z- Site Address(Please include street name,street number and city) c- Directions to site Is your property within 200'of the following: Body of Water(Name) 400 Saltwater Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New Add Alt Repair Other Use of Building Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric Type of Fixture No. of Fixtures Fees LPG Natural Gas Heatpump Toilets Type of Unit No. o� Fees Bath Basins Furnace j Bath Tubs Heatpumps Showers Vent Fans Water Heater Propane Tank Laundry Wsher Gas Outlets _ { Sinks Wood/Gas/Pellet Stove Dishwasher Direct Vent? Other Other Other Other Vgko Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTUREIUNIT. 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 strictures for review and inspection of this project Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 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 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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be aa4'1� done i therevvitl�. changes shall be made without approval. first ing a X Date X7 Datet' t I FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. \ Building Building Department Occ Group Type Constr. Planning Department 1 Other Other Permit Fee SueqF Plan Review Fee UFC Plan Review Fee Plumbing&Base Fee Other Mechanical&Base Fee 0111her WoodlGaslPeW Stave Fee Pre-Paid at Submittal violation Fee TOTAL FEES PERMIT NO.: MASI'ONCbUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98584 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968 APPLIC NT INFORMATION CONTRACTOR INFORMATIO Owner rJ N Contractor Name Mailing (dress c/� Mailin Ad ess City \ vJ Stat Zip Code City Stat Zip Code Phone L O Other Ph.( ) Ph. Q Other Ph. Lien/Title Holder Contractor Reg. # 0 L C_ J Address Expiration '`5- / /�7y_ SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of Sewer System PARCEL INFORMATION-12 digit ax Parcel No. Z Z /4so / <`k ©o 1 ' Fire District Legal Description C. A -, Site Address(Please include street name, street number and city) (- Directions to site Is-your property within 200' of the following: Body of Water(Name) k,�na 11 ('�t+r��r, Saltwater 'Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or Bluffs TYPE OF JOB New �- Add Alt Repair Other Use of Building Location of Fixtures/Units 1st Floor 2nd Floor Basement Garage Closet PLUMBING FIXTURES(Show Number of each) MECHANICAL UNITS Fuel Type: Electric Type of Fixture No. of Fixtures Fees LPG Natural Gas Heatpump Toilets Type of Unit No. of Units Fees Bath Basins Furnace Bath Tubs Heatpumps Showers Vent Fans Water Heater Propane Tank Laundry Wsher Gas Outlets 2— Sinks Wood/Gas/Pellet Stove Dishwasher Direct Vent? Other Other R Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL °. A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT. ?� 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. f 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 spection of this project. Acknowledgment of such is by signature below: OWNER AFFIDAVIT-1 certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a C 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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done i onfor ce therewith. changes shall be made without approval: first obt a roval. X Date X DateC. I i FOR OFFICIAL USE BEYOND THIS POINT i Accepted by `; Date Submittal Amount Due Receipt No. f »C .AIFI<t'j": DS'. >i<€<€€€><>>:<:< <>:::::»>:<::<::<::> .....:::<:<:: C7 :#7F: ... 'I10.1�c: X015 iE ......... . . Building Department Occ Group Type Constr. k Planning Department i Other 1 Other ........:.:::.::.::::::::: �a i i Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing&Base Fee Other f Mechanical&Base Fee Other Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES PERMIT NO.: �.. MASON tbUNTY PLUMBING/MECHANICAL PERMIT APPLICATION 426 W.Cedar/P.O.Box 186,Shelton,WA 98594 Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968 APPLICANT INFORM TION CONTRACTOR INFORMATIO y Owner zk) Contractor Name �, — Mailing A dress A c� Mai4n9AdMe ss c City vJ Statq,�]_ Zip Code City ,� Statet,^ Zip Cod Phone( Y,�t7K5Eg,0 Other Ph.( Ph. O 7 Other Ph.0 Lien/Title Holder Contractor Reg. # L Address Expiration_/ / -t SEPTIC INFORMATION Connect to New Septic Existing Septic_N<-- _Connect to Sewer System Name of Sewer System PARCEL INFORMATION-12 digit Tax Parcel.�o. ZZ2 t /�/ 9 n o 1 l Fire District Legal Description r.. Site Address(Please incluerCstreet name, street number and city) t u Directions to site Is your property within 200' of the following: Body of Water(Name) Saltwater ✓ 'Lake River/Creek Pond Wetland Seasonal un f Stream opes or f Bluffs TYPE OF JOB New ✓ Add ✓` Alt Repair O er se of BuildinW Location of Fixtures/Units 1st Floor 2nd Floor Ba ment Garag Closet PLUMBING FIXTURES(Show Number of each) MECH C TS Fuel Type: Electric Type of Fixture No. of Fixtures F es LPG ral Gas Heatpump Toilets T f U No. of Units. Fees Bath Basins rna Bath Tubs He umps Showers nt Fans Water Heater ropane Tank Laundry Wsher Gas Outlets 2„__ Sinks Wood/Gas/Pellet Stove Dishwasher Direct Vent? Other Other, Other Other Base Fee Base Fee TOTAL PLUMBING TOTAL MECHANICAL ... A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT. 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-1 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 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 is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work conformance therewith. No changes shall be made without first obtaining shall be done i onfor nce therewith. o changes shall be made without approval. first obtai�ing royal X Date X 1 �• Date t -VV FOR OFFICIAL USE BEYOND THIS POINT Accepted by Date Submittal Amount Due Receipt No. i, ............................. »>:<:::>:::«::<:::::<::>::>:>At�FtCltt.�t3s�»:::C�KEi�!................xxx ................ Building Department Occ GroupType Constr. Planning Department Other Other Permit Fee Site Inspection Plan Review Fee UFC Plan Review Fee Plumbing&Base Fee Other Mechanical&Base Fee Other Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( ) Violation Fee TOTAL FEES FORM MUST BE COMPLETED IN INK PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION RR Case No. Name PARCEL NUMBER ZZZI(-Sb—100 L k Date Z-,� SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the site plan Lot Dimensions Fences N Existing Structures Driveways Structure Setbacks Shorelines . ll Water Lines Topography V�J 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 line4 I e p Cp„y`p, I E-adjacent property line I I 1 I I I 1 I I I I I I 1 16- I I I I i YWI 1 I ` I adjacent property I ne4 t Vh7 4 <-adjacent property line SAMPLE SITE PLAN adja t property line-> 32-0' _ E-adjacent property line I f7 30' Flz_ vj gel SEALM w/AI_ A "I HOMt I H, a LA-s r I Ou3Q I j Prix PostD 1 I 1*-- 60' I I VAC.AwT T C ARACv1 t i I G0.oPasCD t �k �\ I A"=L&LTW0.AL SO I I I 1 I /oo' I I I t L—e-LL t x� /00• — J� adjacent property line- ; I , c <-adjacent propertV line 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 diSt�r+G� 'f'o rreti�t.�Yt dtstancm P �G Signature / Date