HomeMy WebLinkAboutBLD93-1481 BLD2005-00395 BLD0064 #28 - BLD Permit / Conditions - 9/14/1993 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION �y
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 22 �C
PLEASE PRINT
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#1 Owner �1 f e� !-iuwan+ —Phone#- r 'S- 1�17
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Site Address N Toe S e 17- ,?R Fire District#
City 2 a2 P' St W 0, Zip I?R
let
T l`r�s•7 Ta/C e c� f'r cr t` d- : fir �^ 'i ' ;:'t =€ ao .`!1 '- -
1
Owner Mailing Address lf'rcd D Lira vl P Q BOX 7 /q
City 3 e 1ta 4 St LAJ a Zip 9 $a
Lien/Title Holder ✓f f' / "�
Address
Clty St Zip
#2 Contractor Name Contractor Reg #
Address Expiration Date
City St Zip Phone#
#3 If septic is located on project site, include records.
Connect to Septic?y Public Water Supply Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
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#4 Parcel No. - - 7 j U —SAn F� 16�7 T�l�!}�
Legal Description /�I 0 �r �e o h! e I7P r' �o t C`�nY�(d'ek 1 BB�
#5 Buildin uare Footage: (existing/proposed)
1st FI i�S4 llZoeTO 2nd FI / 3rd FI / Loft /
Basement / Deck #bedrooms 3 / 3 #bathrooms _/
Garage / Carport / (Circle:Attached or Detached?)
Other sq.ft. /
#6 Use of building res Oler)C e Describe work
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year /980 Make eclma Model &+04 Fear k
Length Ko Q Width �8 Serial No. //810131
# Bedrooms -3 #Bathrooms o- Type of Heat F-1eG+r r G
Purchase Price$ 1 10 900. 0O
#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
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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 E
Proposed Improvements ✓ Easements
Name of Flanking Street Indicate Directional by IN, S, E, W)
Name of Fronting Street in relation to plot plan
A PLICANT TO DRAW SITE PLAN BELOW _
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APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
- -70
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures($6 each)
No. a Toilets CIRCLE FUEL TYPE: Gas, lectri ,
Bath Basins Heatpump, Other
d. Bath Tubs N_Q Units Fees
I Showers J_ Furn BTU
I Hot Water Htr Healpwdps
I Laundry Washer Vent Systems
I Sinks 3 Spot Vent Fans
,Z Floor Drains No. Boilers/Compressors
Laundry Basins HP
l Dishwasher No. Air Handling Units
'. .\ _Disposal _ cfm#
r ? Urinals Fire Protection Systems
c Oth Auto. Fire Alarm Sys 50.00
ed Fire Supp. Sys 50.00
Permit Basic Fee 15.00 Auto ire Sprink Sys 25.00
TOTAL PLUMBING $ Other
Gas Outlets
Wood, Gas, Pelle love
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 APERIOD TOTAL M EC HAN I CAL $
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 OBT IN APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEEPPAR DEPARTMENT.
X OWNER X BY
DATE �� S 2� 3 DATE
FFOROFFICIALTUEONLY:Accepted by. Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
q�d��a�
1d
Environmental Hea/Ith 'wv`r'�^
I
Building Plan Review C— Spec-� /! ,,j4C �7 6—/S-U
LC-
Occupancy Group: M 7 K'<eType of Const:_
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit
�� �' r r ' Plan Check
2C a`s q ✓aPaM fr— Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other
Other
Building Valuation: TOTAL FEE
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