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HomeMy WebLinkAboutBLD92-0941 BLD0362 BLD15124 Mobile Home #8 App for Determination of Adequacy - BLD Permit / Conditions - 8/19/1992 Permit No. cry-CCFW MASON COIINTY '\ BUILDING PERMIT APPLICATION PWU "IMT pp'' / OwnerC{� 46(4 {� nna, Ql<t-,&%'�F?hone# �7J S 37 Site Address City St a p E5 Directions to Site � P7 I I In b:I e w A r Ir 10 awe 4 Owner Mailing Address I r City '(-� St k�) Zip RCS Lien/Title Holder_Na n e Address City St Zip L, Contractor Name ba'e- S 1 n L3 ti Contractor Reg# �! Address Expiration date City d�e�e � a�. StWAZip 983/o/o Phone II (3 If septic is located on project site, include records. Connect to Septic? Public Water Supply Well (If residential, proof of potable water may be required) h #4 Parcel No. 1��3� -� CM Jo Legal Descriptio /✓ c k y v �� #5 Building Square Footage: (existing/proposed) 1st F1 / 2nd F1 / 3rd Fl / Loft / Cement / Deck #b/ edrooms _ #bathrooms_ 1" Garage / Carport / (Circle: Attached or Detached?) Other sq ft / #6 Use of building Describe work #7 Type of Job: New Add Alt Repair Demolition Woodstove Re-Roof Bulkhead Other (#8! MOBILE HOME INFORMATION Model Year LIJ Make CAI-Ae`Dt` Model_Gu PrJ-o Length `-�L _ Width I ,1 Serial No. #Bedrooms #BathroomsI Type of Heat tle��c ;c 1 )aa #P Any water on or adjacent to property: saltwater lake river pond wetland seasonal runoff ocher— — show following on the site plan I Lot Dimensi6ns Flood Zones Existing "Structures Fences Structure Setbacks Driveways Water Lines Shorelines Drainage Plan Topography Septic Systems Wells Proposed Improvements Easements Name of Flanking Street Scale: Name of r roaring Street Date: APPLICANT TO DRAW SITE PLAN BELOW f R l at4 APPLICANT TO DRAW TOPOGRAPHY PROFILE BELO•' y -p h" Plumbirc Fixtures (S2 each) z2a No._Toilecs _Vent Systems X 3 . 00 _Bath Basins _Vent Fars X 3 .00 _Bach Tubs No. Boilers/Compresso Showers 0-3 HP 6 . 00 c Water Htr 3-15 HP 6 . 00 _La ^y Washer 15-30 HP 5 . 00 _Sinks 30-50 5 . 00 _Floor Ora 50 + HP 5 . 00 _Laundry Basi No. Ai iaq unit _Dishwasher 10000 cfm. 7 . 50 _Disposal 10000 cfm. 7 . 50 _Urinals Other _Other < _Evan Coolers < _Hoods Permit<Basic Fee _Fire Suppression TOTAL PLUbIDING $ _Domes. Incin. Cn=l. Intro. loc/Repair 6 . 00 Mechanical F Ga tlets X 2.00 No. Fuel Types Woodst separate _Fern < 1 BTU 6 . 00 _Other _Furs 100K BTU 6.00 Floor 6. 00 Permit Basic Fee 10 . 00 Heat Pumps 6.00 TOTAL NECEMCAL NOT CZ: THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTROCPION AUTHORIZED Is NOT COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANYTIME AFTER WORK IS COMMENCED VI OVUM AFFIDAVIT OON 7JLCT0RS AFFIDAVIT CERTtA TNAT I AN now FEW TR REWIRHim OF TR I CERTtFT TEAT I AN A CURRENTLY REGISTERED CUNITRACTOR CONTRACTORS RNGISTRATTON LAW Sol IB.ZT . AND AN AIARN IN TIME SLATE OF VASNIACTdI AR I AM AWARE Of TEE OF TEE MASON =Arty MIK40U REGUIRENVITS FOR VNICN OUOMANCE REOIIREMENTS REGULATING TR VORR FOR toICE THIS FERNIT IS ISSUED AN THAT ALL VORE DONE VILL K IN IRE PERMIT IS ISSUED AN ALL WXC DOUR VILL BE IN CdIFOAMMCE TNINEVITN. ND oUxGES SWLL K MAN! CONFORMANCE TEEREVTTE. AO GAUGES SINLLL BE WAR VITEOUI FIRST OBTAINING APPROVAL FROM THE BUILDING VITNOUT FIRST OBTAINING AFFEOVµ FROM TR BUILDING DEPARTMENT. r DEPARTMENT. X ONVIE L,. 11 _ ram. z a: RetTsra permit to: Department of General Services 426 W. Cedar/P.O. Boa 186, sheiton, WA 38584 427-9670/1-800-562-5628 FOR OFPICSAL USE ONLY: Accepted by: Date: DEPARTMENTAL REVIEW FOR OFFICg WE OALT Approved Cana Held �Pprwel Planning: � Iz Fhsviradsmeatal Health: I Mr Building Plan Review: OCcupaacy Group: Fire Marshall: Other: ------------ ---------------- QSpecial Conditions: q OSite Inspection ' q q q gBuilding Permit I q n II q q gviolacian Fee I q q q q q gviolaciaa Investigation Fee q q q q p Plan check I q q q q i MUMbing Fee I q qgMechanical Fee I q q q W goodscove Fee II II � q II II gBuilding Stace Fee C i q IlBuilding valuation: II q I TOTALI q MASON COUNT PARTMENT OF HEALTH SERVICES POST OFFICE BOX 186 'Ool SHELTON, WA 98584 ( 427-9670 FA FAX 427-84258425 CATION FOR DETERMINATION OF ADEQUACY ,001 INSTNAONS 1. Complete Part 1. No determination can be made until Part 1 is fully completed. 2. Complete only the portion of Part 2 applying to the type of water system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION ilIlt]liiii?ilii7ilill4gii❑itli(liii?lillillll(Ii?l?llliillltlt Lllhil{lIIIIIIIIiiliili((�!Ilillillllllll(?!(�t?lilili1711lIIilititilillii?dtillllllllllUl?111IItUi?IIIt1111111 NAME OF APPLICANT CA(IO``S /J L�u.c� dE tJr`� DATE d —'/�/ — /c5-- MAILING ADDRESS ���dS J:C tc IL . TELEPHONE s�in ASSESSORS PARCEL'NITMBER . e / , -C _ S. R Q< SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASO(yN, FOR APPLICATION (Check One) APublic/Community Water System Building Permit, Single Family Res Individual System, Drilled Well Building Permit, Commercial Individual System, .Dug Well Building Permit, Replace/Remodel Individual System, Spring Land Use Application Name Individual System, Surface Water Type Individual System, Other C3 Other PART 2-A: PUBLIC WATER SYSTEM IIIIII(IIIIIIIIIIlIltItlllllllltllllilillt7111llittll11111111111(iilllllllllllfllllltlltitlllllllilll21111iiU11lillllllllliilitillll111111111111111ltllllliti{Ilillkti11111t1 NAME OF WATER SYSTEM /�,SU ��,Qh-(�1 ,(� 1�i WFI ID The water purveyor for this system has previmaly filed a certificate of water adequacy with the health district. Y—� I as manager of the above referenced water system. The water system has DOe approval for aer�ice connections, with /// )connections presently in use. The applicant has approval to connect to this water system. Service of water to the applicant for domestic purposes is consistent with both the water system plan and the water right permit presently in effect. water lines are available to the applicant's property line, or the applicant has made satlsfacto a(r�/r/aP(/�q/ n/is�, to extend/the lines. 17^ SIGNATURE OF SYSTEM MANAGER `t (/ PART 2-B: INDIVIDUAL WELL 1- l .it: S u WELL DEPTH Ft WELL CAPACITY Gallons/minute Gallons/Day ❑ well log is attached to this application ❑ Well capacity test results are attached to this application NOT5s: Well Capacity tests are often performed by the well driller at the ties the well is Constructed. Test results frog the" tests are noted on the well log. pasulte from the" tests will be accepted by the health department. If & Wall log cannot be located by the applicants a "'*11 =Pac'ty test """ be PDrfcr=d by & licensed contractor. Baler or pump tests are acceptable, Provided fftabill=tion of drawdovo has been zessured and reeardied. ❑ Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER i 11111111111111111111H111 ❑ WDOE permit is atta44d to this application I have reason to believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT DATE .RELATIONSHIP TO APPLICANT 110=: In addition to Prov1d1nq the above stat,,,,t, the applicant will need to arrange as on-site i3`4960tiOU by the health dixtrlirt prior to determination of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) SATISFACTORY DETERMINAT,$ON: Applicant's water supply appears adequate to meet needs of its intended use. NO"s This detainunation does not address adequacy of the distribution systm, gu,,mt,,, M adequate supply Of water indefinitely into the future, or guarantee compliw" with all applicable WWz ester ressourcno regu- lations. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade— quate to meet needs of its intended use for the following reason(s) : HEALTH INSPECTOR DATE BUILDING PERMIT APPLICATION MASON COUNTY DEPARTMENT of GENERAL SERVICES P.O. BOX 186 SHELTON, WASHINGTON 98584 427-9670 DATE ISSUED PERMIT NO.©3 02 `D� DIRECTIONS OWNER NAME / MAIL ADDRESS_ � CITY&STATE ZIP PHONE 2' TO JOB SITE a2� PARCEL NUMBER ��33�- 56 LEGAL '�GC2� DESCR. G I-00A/ g� / p"/c CONTRACTOR NAME MAIL ADDRESS CITYB STATE LICENSE! LICENSE NO. ZIP PHONE USE OF BUILDING CLASS OF WORK r NEW x ADDITION ALTERATION REPAIR MOVE REMOVE DESCRIBE WORK BEDROOMS DECKS ♦ --1�-- egRPoar [• NOTICE BATHROOMS .L TOTAL SQ.FT. GARAGE / SEPARATE PERMITS ARE REQUIRED FOR PLUMBING. HEATING. VENTILATING OR AIR CONDITIONING. NO.OFSTORIES BASEMENT _ ATTACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT TOTAL SO.FT.L� FIREPLACE DETACHED COMMENCED WITHIN 180 DAYS, OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED. PERMANENT SHORELINE SEASONAL OWNERSAFFIDAVIT CONTRACTORS AFFIDAVIT 1 CERTIFY THAT I AM EXEMPT FROM THE REQUIREMENTS OF THE CONTRACTORS I CERTIFY THAT I AM A CURRENTLY REGISTERED CONTRACTOR IN THE STATE OF REGISTRATION LAW RCW 18.27, AND AM AWARE OF THE MASON COUNTY ORDINANCE WASHINGTON AND I AM AWARE OF THE ORDINANCE REQUIREMENTS REQUIREMENTS FOR WHICH THIS PERMIT IS ISSUED AND THAT ALL WORK DONE WILL BE WORK FOR WHICH THE PERMIT WORK DONE WILL BE IN REGULATING THE IS ISSUED AND ALL IN CONFORMANCE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT FIRST CONFORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITHOUT FIRST OBTAINING OBTAINING APPROVAL FROM THE BUILDING DEPARTMENT. APPROVAL FROM THE BUILDING DEPARTMENT. XOWNER TE XBY --. DATE___ _ FOR OFFICE USE ONLY DEPARTMENT APPROVED DEPARTMENT APPROVED YES NO res No BUILDING VALUATION 3� O�V HEALTH PUBLIC WORKS PLANNING FEE FIRE BUILDING PERMIT M1 .i D.O.T. BUILDING l6" PLAN CHECK SPECIAL CONDITIONS BUILDING GROUP _3 PRE-INSPECTION SHORELINE i 3/O d V aUX R Ze WOODSTOVE PLUMBING MECHANICAL STATE BUILDING FEE t� 3 J STATE SURCHARGE APPLICATION ACCEPTED BY PLANS CHECK BY APPROVED FOR ISSUANCE PERMIT VALIDATION 61_/6-/-/ BY `'��6'Y/ CASH CK MO TOTAL /�,j SiJ BUILDING PERMIT APPLICATION MASON COUNTY P.O. Box 186 Shelton, Washington 98584 426-5593 DATE ISSUED—/�,�-�f_ ' PERMIT NO. �1LZ/ — OWNER NAME // —� MAIL ADDRESS 7 &STATE ZIP PHONE PJen) J, ST 1c H J � ss Fti K L /<JA �'S L� -T -7 5 -rI DIRECTIONS TO JOB SITE oC (JP✓ LEGAL hh /y'1c G I f I (C SEE ATTACHED SHEET)��'y1,-.,, DESCR. - :J-� Syt IM �' ICI `.✓1 S ��✓3'Jf' Y CQI�d�n Y�'C.�� ( Tr, ofL� N ME MAIL ADDRESS CITY 8 STATE LICENSE NO. PHONE CONTRACTOR �/p42 Nla l�;�e � ,•-.-�.S USE OF BUILDING / C. 51 13 R , <_ L Class of work: ❑ NEW ❑ ADDITION ❑ ALTERATION ❑ REPAIR El MOVE ❑ REMOVE Describe ork: L.�Cr� L cUPc— mob; L-e- I9y3 1,91x6 Valuation of work: $ n �!� PLAN CHECK FEE PERMIT FEE SPECIAL CONDITIONS: BEDROOMS= - I DECKS CARPORT :.I NOTICE BATHROOMS�� TOTAL SO. FT — GARAGE I . SEPARATE PERMITS ARE REQUIRED FOR PLUMBING, HEATING. VENTILATING NO. OF STORIES BASEMENT ATTACHED J OR AIR CONDITIONING. TOTAL SO, FT. FIREPLACE ..I DETACHED THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHOR- CONTRACTOR AFFIDAVIT IZED IS NOT COMMENCED WITHIN 180 DAYS,OR IF CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FORA PERIOD OF 180 DAYS AT ANYTIME AFTER I certify that I am a currently registered contractor In WORK IS COMMENCED. the State of Washington and aware of the FOR OFFICE USE ONLY ordinance requirements the regulating the work for which the permit is issued and all work done will be in conformance therewith. PERMANENT)_ SHORELINES ' SEASONAL FLOODPLAIN Firm E.D. NO.__. S.E.P.A. . By Special Approvals IN OUT YES APPROVED NO Lic. No. Date ZONING PLANNING DEPT. HEALTH DEPT. OWNERS AFFIDAVIT PUBLIC WORKS I certify that I am exempt from the requirements of the FIRE MARSHAL contract or registration law RCW 18.27, and am aware BUILDING DEPT. of the Mason County ordinance requirements for which this permit is issued and that all work done will ROAD ACCESS be in conformance therewitah. G�,�� / MOTOR VEHICLE PERMIT Owner - � WL.107ATgOCCEP-GED� PLANS CHECK BV BPPROVED FOR ISSUANCE PLAN CHECK VALIDATION CK. M.O. CASH .C// PERMIT VALIDATION CK. M.O. CASH ST. JOHN, Steven D. #15124 1-26-84 Sam Theler's Ho(Garden Garden Tracts Tr. 20 32-23-1 20 Rossell d. 8 Belf air, A-Sh.__9$5'28 779=9183 Contractor Harbor Mobile Homes Mobile Home $17,094.00 f" mrot'n ro �f mro cn (ny b o n F+• p w o m r o r• H o m o 'o m x w O p rr rt O m G O H w C rt o m rt 0 4 H A' F '0 w m m M p' p. m g r m r r PI n .. w cr 'o K P• w w m R' m F.' •• µ µ p 1+ CA r p w O O :3 !17;' p w f) r tom• w O F• rt w OQ rt 00 � o nn maQom .. � .. � � r mfD o o m a a o l a. w H. r µ p a m fir •-S T: 4• P