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Date By Date By FINAL INSPECTION Water Line Date By Date By � ,�. n. . - � Date By T KIT El)lt0J EA[LE —7 1 R 10q -7 i o RLS 11 CLWFULT oaf AWzIraz o QL64 S 9ACy QDUV i `VUOIY- ®CC tov-d l�S ca v )o R xx-to w im cV U) All 3 � c Q� MA�ZS loll �G,u oFf C o o w J y 0 V COM �VN 1 ED MASON COUNTY 4 ?,1 CHANGE IN TENANT APPLICATION 4��t tReugg, �je in Tenant Application and return with a floor plan,site plan,septic pumper's report,septic records and fee to the Masofi. Center, P.O.Box 186, Shelton,WA 98584. Evaluation of the Change in Tenant Application will involve staff members from Fire Marshal, Environmental Health, Planning and Public Works offices who will identify compliance requirements. This application is intended for tenant change only. If construction or remodeling is proposed or required a building permit will be necessary. Upon approval the permit will be issued to the applicant/tenant. After the permit is issued,schedule an inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be posted in a cons icuous lace on the premises. Date: q— a y Assessor's Parcel Number: Legal Description: Building Site Address: 7 q 2 57= P 7- Af S c/ 2_ Method of sewage disposal: %-peptic O Sewer L name of district: Water source: O Individual Well O Community Well 0 Public System, name of system: Name of Applicant: c�FZ ,camp y G g-"7c- - I S---S G.G 1! 4 Mailing address: 31 e!:-=- L L I<A dz P, -Ape— City: U,y/o,� State: Zip: 6z S 5� Day phone:.j�o Contact Person: L we-r- z o.4'da Message phone: s , M Proposed business name: Proposed use: s Number of em loyees: Previous business name: Describe previous use: :5 4 Check one: O Detached single level/single tenant O Single level/multi tenant 0 Multi level/single tenant O Multi level/multi tenant Age of structure: Is structure currently If not occupied, how long has it been vacant? occupied? Yes No Yr. Mo. i Squarefootage: I Basement: First: o Mezzanine: —I Second: SSo 'Third: a " Is the structur0 heated? Heating type: Circle one: Circle one: es No Electric Liquid Propane Natural Gas Oil Type of heat: Circle one: Furnace Heat Pump Electric baseboard or wall mount Radiant Will there be any changes to the following? Circle yes or no,if applicable: Floor lay-out: Yes No Lighting: N Heating: Yes �N9) Exterior Finishes: Yes Interior Finishes: Yes No Parking: Yes o Number of restrooms provided: Number of fixtures in each Is structure handicap accessible? Circle one e No Is the structure equipped with a fire sprinkler system? Ye No Fire alarm system? es No Monitoring Station Name: Phone number: I. Floor Plan(5 sets): • Draw the floor plan to scale • Use of rooms • Room Dimensions • Location of all exits and windows(include dimensions) • Location of plumbing and mechanical fixtures • Interior doors with swing radius 2. Site Plan(5 sets): Note scale used • Property lines,easements,&right of ways • Location of all existing structures&dimensions • Distance,in feet,from property line&structures • Landscape buffer yards • On-site sewage tanks and drain fields,&reserve • Well location • Location of fire hydrants&vehicle access roads • Parking areas number&arrangement) 3. Septic records,pumper's report or O&M report 4. Fees will be collected at time of submittal Accepted bV Date Submittal Amount Receipt number Department Review i als Date Comments Building 2 Environmental Health Fire Marshal Planning - Public Works Occupancy Change? (circle one) Yes Qo Type of construction Occupancy classification change from o Occupant load calculated: persons Existing occupant load design persons. Land Use Designation: Occupancy Classification: IyF �I��L�-'C�lIy C��V�D MASON COUNTY COM JUN 4 ?00 CHANGE IN TENANT APPLICATION 42�{Ip�t the Change in Tenant Application and return with a floor plan,site plan,septic pumpers report,septic records and fee to the Masofi ��cctt�►it Center,P.O. Box 186, Shelton,WA 98584. Evaluation of the Change in Tenant Application will involve staff members from the ultg, Fire Marshal, Environmental Health, Planning and Public Works offices who will identify compliance requirements. This application is intended for tenant change only. If construction or remodeling is proposed or required a building permit will be necessary. Upon approval the permit will be issued to the applicant/tenant. After the permit is issued,schedule an inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be posted in a conspicuous lace on the premises. Date: — rs y Assessor's Parcel Number: Legal Description: Building Site Address: 7 le 5 T 6 v y,�,4,, �7 Method of sewage disposal: 0-septic O Sewer-:-name of district: Water source: O Individual Well O Community Well * Public System, name of system: Name of Applicant: Mailing a dress: .3 l � 1A ez P, -Age— City: State: Zip: s y"21 -- Day phone:.SGa-,S-qV-ys/ Contact Person: (fl{E 7- L a Ada z- Message phone: 5 Proposed business name: t3l e Oe 15 S?-v Alp- 4- Proposed use: 5,W /_, P, Number of em loyees: Previous business name: Describe previous use: :5 r Check one: O Detached single level/single tenant O Single level/multi tenant ® Multi level/sin le tenant O Multi level/multi tenant Age of structure: a x Is structure currently If not occupied, how long has it been vacant? occupied? Yes No Yr. Mo. Square footage: I Basement: .�- First: o Mezzanine: _, , Second: gSoIs the structure heated? Heating type: Circle one: Circle one: es No Electric Li uid Propane Natural Gas Oil Type of heat: Circle one: Furnace Heat Pump Electric baseboard or wall mount Radiant Will there be any changes to the following? Circle yes or no,if applicable: Floor lay-out: Yes to Lighting: N� Heating: Yes Ng) Exterior Finishes: Yes Interior Finishes: es No Parking: Yes o Number of restrooms provided: I Number of fixtures in each Is structure handicap accessible? Circle one a No ,V /'7-- h , r Is the structure equipped with a fire sprinkler system? Ye No Fire alarm system? es No Monitoring Station Name: Phone number: 1. Floor Plan(5 sets): • Draw the floor plan to scale Use of rooms • Room Dimensions • Location of all exits and windows(include dimensions) • Location of plumbing and mechanical fixtures • Interior doors with swing radius 2. Site Plan(5 sets): Note scale used • Property lines,easements,&right of ways • Location of all existing structures&dimensions • Distance,in feet,from property line&structures • Landscape buffer yards • On-site sewage tanks and drain fields,&reserve 0 Well location r• Location of fire hydrants&vehicle access roads . Parkin areas number&arrangement) 3. Septic records,pumper's report or O&M report. 4. Fees will be collected at time of submittal Acce ted by Date Submittal Amount Receipt number Department Review Initials Date Comments Building [Fire nvironmental Health 2 a Marshallanning Public Works Occupancy Change? (circle one) Yes No Type of construction Occupancy classification change from o Occupant load calculated: persons Existing occupant load design persons. Land Use Designation: Occupancy Classification: i -7 i i 22.S , EC,EjV MASON COUNTY COM �'UIV 1 ED 4 ?,1 CHANGE IN TENANT APPLICATION 4��t the ge in Tenant Application and return with a floor plan,site plan,septic pumper's report,septic records and fee to the Masoh it Center, P.O. Box 186, Shelton,WA 98584. Evaluation of the Change in Tenant Application will involve staff members from the uR , Fire Marshal, Environmental Health, Planning and Public Works offices who will identify compliance requirements. This application is intended for tenant change only. If construction or remddelina is proposed or required a building Permit will be necessary. Upon approval the permit will be issued to the applicant/tenant. After the permit is issued,schedule an inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be posted in a cons icuous place on the premises. Date: _ c — �� Assessor's Parcel Number: Legal Description: Building Site Address: 7 1 h c Method of sewage disposal: A-Septic O Sewer-name of district: Water source: O Individual Well O Community Well O Public System, name of system: Name of Applicant: �L <� !✓ i�c' :�7c>- j s Z C s Mailing address: City: .�� .-. State: ; W Zip: 5 �- Day phone: $ ys Contact Person: �NC-T Z-o.moo .z Message phone: Proposed business name: _ Z_ v fry L Proposed use: .� _, 4 s Number of em loyees: Previous business name: Describe previous use: 5 le) 144 Check one: O Detached single level/single tenant O Single level/multi tenant ® Multi level/single tenant O Multi level/multi tenant Age of structure: Is structure currently - If not occupied, how long has it been vacant? y a. .. occupied? Yes No Yr. Mo. �5 t Square footage: I Basement: I First: ,,,- G Mezzanine: Second: Third: — - Is the structur heated? Heating type: Circle one: Circle one: es No Electric Liquid Propane Natural Gas Oil Type of heat: Circle one: Furnace Heat Pump Electnc baseboard or wall mount Radiant Will there be any changes to the following? Circle yes or no,if applicable: Floor lay-out: Yes No Lighting: No,� Heating: Yes Exterior Finishes: Yes Nbi Interior Finishes: Yes No Parking: Yes o Number of restrooms provided: Number of fixtures in each 3 Is structure handicap accessible? Circle one es' o - w Is the structure equipped with a fire sprinkler system�N Ye No Fire alarm system? es No Monitoring Station Name: Phone number: 1. Floor Plan(5 sets): • Draw the floor plan to scale 0 Use of rooms • Room Dimensions • Location of all exits and windows(include dimensions) • Location of plumbing and mechanical fixtures • Interior doors with swing radius 2. Site Plan(5 sets): Note scale used • Property lines,easements, &right of ways • Location of all existing structures&dimensions • Distance,in feet,from property line&structures • Landscape buffer yards • On-site sewage tanks and drain fields,&reserve . Well location • Location of fire hydrants&vehicle access roads • Parkina areas number&arran ement 3. Septic records,pumper's report or O&M report 4. Fees will be collected at time of submittal Accepted by Date Submittal Amount l?'�Z-c,— Receipt number Department Review Initials Date Comments Building Environmental Health Fire Marshal Planning ) (v (� 'Vl tsr ( /�(' Public Works Occupancy Change? (circle one) Yes No Type of construction Occupancy classification change from o Occupant load calculated: persons Existing occupant load design _persons. Land Use Designation: Occupancy Classification: . Range Hood Systems Report ► , f ' /�_r. ` SERVICE COMPANY DATE OF SERVICE l TIME �P_M '1 3a sc) - 1 Oif'�`Q /��"�/ ANNUAL SEMI-ANNUAL RECHARGE INSTALLATION RENOVATION ir ;e Y' a LOCATION OF SYSTEM CYLINDERS !1 P.O..Box 3005 Bremerton, WA 9='310 MANUFACTURER MODEL NUMBER WET DRY CHEMICAL R Phone: 3:':�-�i? CYLINDER SIZE MASTER CYLINDER SIZE SLAVE 141 CYLINDER SIZE SLAVE FUSE LINKS 360'F. FUSE LINKS 450'F FUSE LINKS 500'F OTHER CUSTOMER Name ( I tii P"a 1l02 n v FUEL SHUT-OFF ELECTRIC GAS SIZE �1C7 �� �L L1 r Addresst � '•�:' City jj L SERIAL MBER 7AST HYDRO TEST DATE LAST RECHARGE DATE MANUFACTURER'S MANUAL REFERENCE Telephone Store No. PAGE NUMBER: DRAWING NUMBER: Owner or Manager COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT 1. All appliances properly covered w/correct nozzles 20. Replaced fuse links 2. Duct and plenum covered w/correct nozzles 21. Check travel of cable nuts/S-hooks �. Check positioning of all nozzles. 22. Piping & conduit securely bracketed 4. System installed in accordance w/MFG UL listing 23. Proper separation between fryers & flame - 5. Hood/duct penetrations sealed w/weld or UL device 24. Proper clearance-flame to filters 6. Check if seals intact, evidence of tampering - 25. Exhaust fan in operating order 7. If system has been discharged, report same 26. All filters replaced 8. Pressure gauge in proper range (if gauged) 27. Fuel shut-off in on position 9. Check cartridge weight (If applicable) 28. Manual & remote set/seals in place 10. Hydrostatic test date 29. Replace systems covers 11. 6 year maintenance date 30. System operational & seals in place 12. Inspect cylinder and mount 31. Slave system operational 13. Operate system from terminal link - 32. Clean cylinder & mount 14. Test for proper operation from remote 33. Fan warning sign on hood 15. Check operation of micro switch 34. Personnel instructed in manual operation of system 16. Check operation of gas valve 35. Proper hand portable extinguishers T 17. Clean nozzles 3B. Portable extinguishers properly serviced 18. Proper nozzle covers in place 37. Service & Certification tag on system 19. Check fuse links and clean NOTE DISCREPANICES OR DEFICIENCIES BELOW COMMENTS: - ur .4 On this date, the above system was tested and inspected in accordance with procedures of the presently adopted editions of NFPA 17, 17A, 96 and the manufacturer's manual and was operated according to these procedures with results indicated above. X SERVICE TECHNICIAN PERMIT NO. DATE: TIME: AM PM CUSTOMERS AUTHORIZED AGENT The above service technician certifie$that the system was personally inspected and found conditions to be as indicated on this report. r Brooks Equipment Company,Inc. AUTHORITY HAVING JURISDICTION CO p m w wLU~ Q a w5c Q "' IX a zz e � .L, �o ui O a o H i _ U IL (L O U U Qa z LLI > N Z w O w H w aw n � ww O v d ww otS U Ix v U QU Z W = w Q U) W u. w a � O W � z o aCL z. , � U W w U. 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