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Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 PLEASE PRINT #1 Phone# 3J d Address 116'. S/ 1k14/''X 16'N Z>l , Fire District# �ity /V!O AI _ St R/ Zip 8 Directions to Job Site &c9 fi so 12/ -t-- , N_ Jr � t Owner Mailing Address h City '(7 mail; St Zip Lien/Title Holder 7' U,S E Address `S ,�YJ 411W City v a.� � St Zip #2 Contractor Name I0/ TlS CO/VS-1 (Z U C T J O // Contractor Reg# 96 k / 21/6 J Address a;z,00o IV Expiration Date 2/ 2 / c city ,Q /L z 111:5,g/✓ St GyA Zip Phone# #3 If septic is located on project site, include records. Connect to Septicl�Public Water Supply Wel Connect to Sewer System? Name of System (If residential, proof of potable water is required) #4 'arcel gal Description �jr)dQ-V-V anal ,oh ll� 25 R:f," 1 #5 Building Square Footage: (existing roposed `' 1st FI V 2nd FI 3rd FI / Loft / Basement /-,7 Deck / #bedrooms / #bathrooms / Garage / Carport / (Circle:Attached or/Detached?) Other sq. ft. #6 Use of building S/n/(� /L/ / AZ,��5/A Z/U 7/ 4 Describe work A6'U/L 1� dbbJJ-JoA,1 !o 7-,'/V4,- 1U21,y2f #7 Type of Job: New Add Alt Repair Other #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year Make Model Length Width Serial No —,----- # Bedrooms #Bathroo Type of He t Purchase Price$ #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 ------------- VJ10 _- N O � 0 APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW �r� Plumbing Fixtures ($3 eachl Fee Mechanical Fixtures ($6 eachl No._Toilets CIRCLE FUEL TYPE: Gas, lectri _Bath Basins Heatpump, Other _Bath Tubs No.. unk Fees _Showers Furn BTU _Hot Water Htr _ Heatpumps _Laundry Washer Vent Systems Sinks Spot Vent Fans J T V YvA// �6i,2S _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 15.00 _ Auto Fire Sprink Sys 25.00 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 15.00 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 OF THE 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 FRO THE BUILDING THE BUILDING DEPARTMENT. DEPARTMENT. X OWNER X BY C DATE DATE �J FOR OFFICIAL USE ONLY:Accepted by: Date: DEPARTMENTAL REVIEW FOR OFFICE USE ONLY Approved Cond. Hold Approval Planning: g �Z� Environmental Health: w� Building Plan Review Occupancy Group: Type of Const: Fire Marshal: Other: Special Conditions: FEES Building Permit 2� Plan Check Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee Other Other Q �� Building Valuation: 3'6 -209 TOTAL FEE