HomeMy WebLinkAboutBLD2004-00518 Final SFR - BLD Permit / Conditions - 1/9/2005 co
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MASON COUNTY PERMIT NO.
BUILDING PERMIT APPLICATION
426 W. Cedar • PO. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 • Belfair (360) 275-4467 • Elma (360) 482-5269a1_/'1
On the web www.co.mason.wa.us
APPLICANT INFORMATION CONTRACTOR INFORMATIO
Owner r M. +r L,AIq- Company Name //o
Mailin Address2 0 E_ .4 sTL,F 4.JAY' Mailing Address
CityW�Zip Code �i' 13�1 City/F"L� State _ Zip Code 9g !�
Phon� 0 `�f.Z7-L/DO Other Ph. Phone.?53- 9" —25IC .3 Other Ph.
Lien/Title Holder S ELF Contractor Reg. #)3z: f ai 98/j/C�i'- xp.0Z 1-5- 20
E mail address ""� E Mail Address %nr -^A(c .,ueu6.H cp f�Sliyha..-r�ac •�
Drivers Lic.#C44fiK,C M G MLOB Drivers Lic.# DOB
SEPTIC /WATER SYSTEM INFORMATION - Connect to New Septic Existing Septic
Connect to Water System Name of Water System
Well ±�Water System Name of Water System
PARCEL INFORMATION - 12 Digit Parcel No. 7777 3 /q/000 3 0 Fire District
Legal Description 7_214C T 3 I L - &3 - UV
Site Address (Please include street name, street number and city) E T ✓so.t)
Directions to site /%QoH i-/E'j o fAJ6 7"or,)4 k D i l.Jsa,cl -7-elzV 7-rs-/r leJt'
/=ram s,— Si.✓gk'EA ✓- r/ 166,cT Of Of` EdSo i7
Will timber be cut and sold in parcel preparation?Yes N
Is property within 200'of Saltwater parcel preparation?
River/Creek.Na Pond AIQ _
Wetland�l Seasonal Runoff_ALQ _Stream Slopes or Bluffs > 15%&1 d
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Ye-4143
TYPE OF JOB ; jVewV Add Alt Repair Other PRIMA,R RESI ENCE SEASONAL ❑
Use of Building L]/� Describe Work
No. of Bedrooms No. of Bathrooms2_ Square Footage - 1 st Floor / 2nd Floor
3rd Floor — Basement Deck Covered Deck Other Sq.ft.
Garage=Attached k �Detached Carport Attached Detached
MANUFACTURED HOME INFORMATION - Make Model Year
Length Width Serial No. No.of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit? Yes/ No
Installer Name Certification No.
OWNER/BUILDER Acknowledges submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owners legal representative,or the contractor.I further
declare that I am entitled to receive this permit and to do the work as proposed in the application.I declare that I have obtained the permis-
sion from all the necessary parties.If permission is required from any easement holder or any other party in interest regarding this applica-
tion or the work proposed in the application, I have obtained permission from them to apply for this permit and conduct the work proposed.
X �_ Date: O d
Owner/Owners Representative/Contractor (indicate which one)
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department S5-o'
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee - Site Inspection
Plan Review Fee - EH Review Fee
Plumbing & Base Fee ) nq — Planninq Review Fee
Mechanical & Base fee `�' Other
Wood/Gas/Pellet Stove Fee State Fee —
Violation Fee Pre-Paid at Submittal
Valuation $ Lfl TOTAL FEES
PERMIT NO.:
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.Cedar/P.O.Box 186 Shelton,WA 98584
Shelton(360)427-9670 Belfair(360)�75-4467 Elma(360)482-5269
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner CARL4 AdContractor Name - ST'
Mailing Address - L -r 44 Mailing Address
city,S t LTA Statel )A tip CodetzgictLy City/ FA� State,,,,4 Zip Code q.klire
Phone(.3J)4f27 OOOther Ph.( ..-- Ph. ,S`-t ,p-BSffJOther Ph.( ) —
Lien/Title Holder A/A NE Contractor Reg. #
Address Expiration_--42Z
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
II
PARCEL INFORMATION- 12 digit Tax Parcel No. Fire District
Legal Description /A 7- 3 L L- C)3 -o
Site Address(Please include street name,street number and city)
Directions to site _.a LAO
Is your property within 200'of the following: Body of Water(Name) Saltwater
N
Lake b River/Creek_M4 Pond Wetland Seasonal Runoff_Stream
Slopes or Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building 1 LV
Location of Fixtures/Units 1st Floor Y'� 2nd Floor Basement Garage Close
PLUMBING FIXTURES (Show Number of each) MECHANICAL UNITS Fuel Type: Electric
Type of Fixture No.of Fixtures Fees LPG Natural Gas Heatpump
Toilets Type of Unit No.of Units Fees
Bathroom Sink Furnace
Bath Tubs �� Heatpumps
Showers � Spot Vent Fan �
Water Heater Propane Tank
Clothes Washer Gas Outlets
Kitchen Sinks Wood/Gas/Pellet Stove
Dishwasher Kitchen Exhaust Hood I
Hosebibs 1 Dryer Vent 1
Other-CiP / Other.
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
A FLOOR PLAN AND PLOT PLAN MAY BE REQUIRED DEPENDING ON THE TYPE OF FIXTURE/UNIT.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X L_d�J�,Ci���/ , Date 07 4 X Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
DEPARTNIENTAEREVIESN APPROIFED l3ENIEf3 GONDFTIQN CODES.
Building Department
Occ Group Type Constr.
Planning Department
Other
Other
.. .. ...
Permit Fee Site Inspection
Plan Review Fee UFC Plan Review Fee
Plumbing&Base Fee Other
Mechanical&Base Fee Other
Wood/Gas/Pellet Stove Fee Pre-Paid at Submittal ( )
Violation Fee TOTAL FEES