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CONCRETE M NI ECHACAL TrMOBILE HOME �1
Footings-Setback date_ _ by Ribbons
date by Gas Piping 1 date by
Foundation Walls date by Set Up
date by INSULATION Nate QZL —13—.`�Y �J
BG/SLAB Insulation Floors Final
date FRAMING by J date by I date `�� lq— 5 S by t..—�
Walls
FIRE DEPT.
date by � date by
PLUMBING date _ by — OTHER
Groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
data by date by
Water Line FINAL INSPECTION
date by date by date by
date -- �I
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rw �u'c plf'I /t I ' 4 t1z'X5- Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION dkap�
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 �v'
PLEASE PRINT
#1 Owner /��f ( ` i C r�� Phone#
ddress <^i �i SS Fire District# 02.
St Zi ity p
Directions Job Site 1i✓Eo/o��
Owner Mailing Address �� �fi.-1 n� ��L� L1-5 ,�112
City
Lien/Title older
Address
City ti A, St_-wi±—Zip �.
#2 Contractor Name Contractor Reg #
Address Expiration Date /
City St Zip Phone #
#3 If septic is located on project site, include records.
Connect to Septic? Public Water Supply Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 P el No_' a - 5� - 05 �V u'r� (�eu
Legal Description
#5 Building Square Footage: (existing/proposed)
1st FI 2nd FI 3rd FI / Loft /
Basement Deck #bedrooms #bathrooms
Garage Carport (Circle: Attached or Detached?)
Other sq. ft.
#6 Use of building (L-- Describe work
#7 Type of Job: New Add Alt Repair Other
JAMt-i 7 1995
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year s Make�- Model 61OE. FEALTH SERVICES
Length Width I Serial No.
# Bedrooms_ 2 # Bathrooms ':�' Type of Heat L�L�T� 1 C, Silr CSC C�Ct CSC U
Purchase Price $ 3a . 0C)
#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
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ( 9 each) Fge Mechanical Fixtures ( 6 each)
No._T 'lets CIRCLE FUEL TYPE: Gas, Electric,
_Bath asins Heatpump, Other
_Bath Tub§ NQ Units Fees
_Showers \ _ Furn BTU '
_Hot Water Htr \•. _ Heatpumps
_Laundry Washer _ Vent Syst s
_Sinks _ Spot ent Fans
_Floor Drains NN. oilers/Compressors
_Laundry Basins HP
_Dishwasher NN. Air Handling Units
_Disposal cfm#
_Urinals N Fire Protection Systems
_Other _ Auto. Fire Alarm Sys 50.00
Fixed Fire Supp. Sys 50.00
Permit Basic Fee 15.00 Auto Fire Sprink Sys 25.00
TOTAL PLUMBING $ No. r
Gas tlets
Wood, Gas, ellet 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 15.00
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.
WNER X BY
ATE DATE
FOR OFFICIAL USE ONLY:Accepted by: Dater
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
� I
Planning: se�)g'. , �J x fasn e�'f�' �vL4c4we-5 Q
Environmental Health:
Building Plan Review iM F( S9,-t_T PC S'/ A
Occupancy Group: IZ-3 Type of Const: SN
Fire Marshal:
I
Other:
Special Conditions: FEES
Building Permit t co'w
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other
Other
Building Valuation: TOTAL FEE
Golden Bell Mobile Home Park
N.E. 20 Roessel Rd. Belfair,We 98528
Phone#(206)275-4623
Deede Schattenkerk, Manager
Dept Of General Services
P.O. Box# 186
Shelton, Wa 98584
As required, we are sending you notification of a new lease
agreement with the following new tenant. Lease agreement will commence
when their Mobile Home arrives on our pre-existing lot. If you have any
questions please call during normal business hours.
New Tenant Name:
New Tenant Lot#
Thank You,
?lculc Se�sGler.EczE
Mgr.