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Box 186, Shelton,WA 98584 427-9670/1-800-562-5628 PLEASE PRINT ''QQ #1 Owner N--fir ,Phone# `/2b. �9 e Address Fire District# City A,;#- 'JA10h Q$t$ St Zip Directions to Job Site R mac. -U to AQA rns A&V- t J)zy1ft5S e,. e.,oa,etit Wwt'Ln, Ct�iY fY Inl(t, Owner Mailing Address ,, Wk l ZtO W% &AAZI, VJ City -S"A{b'o St AS Zip Lien/Title Holder Address Clty St Zip #2 Contractor Name ROB'S EXCAVATING Contractor Reg#�oPoSE�t�E o11KQ Address East 1871 Johns Prairie Rd. Expiration Date 'C- City eon, St Zip Phone# qUIP - 607 #3 If septic is located on project site, include records. Connect to Septic?___X_Public Water Supply Well Connect to Sewer System? Name of System (If residential, proof of potable water is required) #4 arcel No. aaaoa- .3} - 000 � Legal Description 'R %J* a t /,�iX ��SO s ��' V6—) #5 Building Square o age: xistln se 1st FI_l nd FI 0- / 3rd FI / Loft / Basement Deck / #bedrooms- _/ .3 #bathrooms/ Z_ Garage / Carport / (Circle:Attached or Detached?) Other sq.ft. / #6 Use of building eSNtA*+w Describe work �r/�fA- #7 Type of Job: New Add Alt Repair Other Yp �— P #8 MOBILE/MANUFACTURED HOME INFORMATION �J Model Year 99 Make 6�4� Model �n1 N ��1004 F Length_ ki Width Serial No. u �,.�,►a , #Bedrooms _#Bathrooms Z Type of Heat 01 Purchase Price$ U�.►�nlbwr� , #9 Indicate by circling the applicable source if any water is on or adjacent to subject property: River Pond Creek Stream Wetland Lake Marsh QEEi> Seasonal Runoff Other Show following on the site plan w 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 Name of Fronting Street in relation to plot plan APPLICANT TO DRAW SITE PLAN BELOW APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW s Plumbing Fixtures ($3.25 each) Fee Mechanical Fixtures ($6.50 each) No. Toilets CIRCLE FUEL TYPE: Gas, Electric, Bath Basins Heatpump, Other Bath Tubs No Unk ,Eggs 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 16.25 _ 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 16.25 WORK IS SUSPENDED OR ABANDONED FOR A PERIOD TOTAL MECHANICAL $ 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 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 FI AINING APPROVAL FROM THE BUILDING THE BUILDING DEPARTMENT. PARTM T: X OWNER X BY DATE DATE — Q� FOR OFFICIAL.USA ONLY:Accepted t DEPARTMENTAL REVIEW FOR OFFICE USE ONLY - Approved Cond. Hold G- Approval Planning: 13C� Environmental Health: Building Plan Review hdw Occupancy Group: Type of Const: Fire Marshal: Other: Special Conditions: FEES Building Permit / Plan Check Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee Ll Other Other Building Valuation: TOTAL FEE