HomeMy WebLinkAboutBLD2004-01142 Final SFR - BLD Permit / Conditions - 3/17/2017 J (n M
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MASON COUNTY PERMIT NO.b
BUILDING PERMIT APPLICATION
426 W. Cedar r-AO. Box 186, Shelton, WA 98584
Shelton (360) 427-9670 • Belfair (360) 275-4467• Elma (360) 482-526
On the web www.co.mason.wa.us �
APPLICANT INF RMATIO CONTRACTOR I ORMATION
Owner Company Name
Maili Addres Mailing Address
City St to Zip Cod City State Zip Code
Phon O her P Phone Other Ph.
Lien/Title Holder Contractor Reg. # Exp.
E mail address E Mail Address
Drivers Lic.# DOB 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 INFORM ION - 12 D� t P rcel No. ire i r t
Legal Description
Site Address (Please i u e s reet n me, st a um and y
D recti ns to site
i1 timber be r-,it'aiRl sold in parcel preparation. Yes/
Is property within 200'of Saltwater Lake eOf _River/Creek Pond
Wetland Seasonal Runoff Stream Slopes or Bluffs > 15%
Is this permit submittal the result of a Stop Work Notice,Correction Notice or other enforcement action?Yes/No
TYPE OF JOB - New Add Alt Repair Other RiMARY R IDE E SEASONAL ❑
Use of Building _Describe Work
No. of Bedrooms—No.of Bathrooms �� Squ e Footage - 1st Floor 2nd Floor !uq
3rd Floor Basement Deck Covered Deck Other Sq.ft.
Garage Attached 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.
Date:a--(�"tJ'-�(
X Owne ners Fte r_esentative/Contractor (indicate which one)
FOR OFFICIAL USE BEYONDTHIS POINT
Accepted by: Planning Pd Ck# Date Bld Pd Receipt No.
DEPARTMENTAL REVIEW APPROVED DENIED NOTES
Building Department 31 -Q
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
FEES
Building Permit Fee Site Inspection
Plan Review Fee Jf 4 EH Review Fee
Plumbing & Base Fee 0 //0 Planning Review Fee
Mechanical & Base fee .1 o Other
Wood/Gas/Pellet Stove Fee State Fee —
Violation Fee
Pre-Paid at Submittal c35
Valuation $ l(, a0(p s s TOTAL FEES
PERMIT NO.:
MASON COUNTY
PLUMBING/MECHANICAL PERMIT APPLICATION
426 W.
Shelton(360)27-9670/Beellf ir(3606
�1754467'Elma9360) 82-5269
APPLICANT INFORMA 10 CONTRACTOR INFORMATION 1
Owner — Contractor Name cL1-6-11 U 4J 4—
Mailing Address Mailing Address
City. S ate i id ip Code City State Zip Code
Phone Ot'f er Ph. Ph.( Other Ph.(�
Lien/Title older Contractor Reg. #
Address Expiration
SEPTIC INFORMATION-Connect to New Septic Existing Septic Connect to Sewer System Name of
Sewer System
PARCEL INFORMAT N- 12 digi Tax Parcel No. / /N 71 Fire istri
Legal Description — y'• Ca
Site Address(Please in ude street name, re nu ber an city)
Directions to site
Is your property within 200'of the following: Body of Water(Name), rs` t�[Q Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream
Slopes or Bluffs
TYPE OF JOB New Add Alt Repair Other Use of Building
Location of Fixtures/Units 1st Floor��2nd Floor Basement Garage Closet
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. f nit Fees
Bathroom Sink Furnace
Bath Tubs Heatpumps
Showers V� Spot Vent Fan
Water Heater Propane Tank
Clothes Washer �_ Gas Outlets
Kitchen Sinks �_ Wooq Gas ellet Stove
Dishwasher Kitche xhaust Hood —�
Hosebibs -�— Dryer Vent
Other 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-1 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.
)(11� -Dat42L aq X 61 Alow Date
FOR OFFICIAL USE BEYOND THIS POINT
Accepted by Date Submittal Amount Due Receipt No.
OEPitfiLMENTALREViElt3f A't�ROVED Q NIED GONDITION:: ODES
Building Department �
Occ Group Type Constr. d S
Planning Department
Other
Other
.. .::..::::::::.... : FEES ::i::: :<::z:::::':::#[«: >:: :::> :<:
::::::::::::::::::::.:..:::::::.::.:::.::::.:::::::....:.:.....................................................................................
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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