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CONCRETE 101 4 e-
MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date t/- by ✓ Gas Piping date b
Foundation Walls date a — y
� Set Up
date '� by %��, INSULATION �, b date by
BG/SLAB Insulation Floors Final
date FRAMING by date Z— by date by
Walls FIRE DEPT.
d by date 'Z by date by
PLUMBING OTHER
Groundwork Attic
date by date -,� / j
D.W.V. WALLBOARD NAILING INS
date z — - by date 12 - `i by L✓ �Ic 6)1a �-}'1
Water Line FINAL INSPECTION f�
date by '� date �� by L1 date by
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Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
(Calling From: Seattle 464-6968, Belfair 275-4467, Elma 482-5269)
PLEASE PRI
#1 caner 74 ryl 011 Phone# ('-26 2.7 I-552,0
Site Address �1 ApoClo I L� Fire District#
City Ss�rs,�- 1 6U[P C.�25G�Mct ri \ y _ St V'JA-- Zip qgS fS
Directions to Job Site
_oC ��
Owner Mailing Address 2M72 <- ;ra -\ �T
City V_ 11r_ l St WA- Zip'I�Z)sn
Lien/Title Holder C SG - C bd�
Address t J ?=� ( ( LA_U ;i &n
City ?aa ! a St Ly ZIP his
#2 Contractor Name 1Jt'r�n 1 F�5gl^-) Contractor Reg#4
Ex (ration Date / 1 -1
Address ��� �'1�� ��� � '� �\ ��" p —��-
City y u f St Zip ; , r —Phone# '
#3 If septic is located on project site, include records.
Connect to Septic? Je5_Public Water Supply .�;,_Well
Connect to Sewer System? Q 0 Name of System
(If residential, proof of potable water is required)
# Parcel No. - Lot
Legal Description -b( V Lot r
#5 Building Square Footage:
1st FI ! 2nd FI 3rd FI Loft Basement
# Bedrooms 2 # bathrooms Deck !�;oy Other "�n
Garage cev'K Carport (Circle: Attached or etache .)
#6 Use of building V(a (c2fi r� trn K , o Describe work cc�L
�ff��stryC''h M/,-
#7 Type of Job: New _Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year Make Model
Length Width Serial No.
# Bedrooms # Bathrooms Type of Heat
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 arsh Saltwater Seasonal Runoff Other
Show following on the site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Drainage Plan Wells
Septic Systems Easements
Proposed Improvements
Name of Side Street Indicate Directional by (N, S, E, W)
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
i
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5 Iy�q�
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
L
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f/r& 3,c>
r
Plumbing Fixtures ($3.35 each) Fee Mechanical Fixtures ($6.75 each)
No. Z Toilets CIRCLE FUEL TYPE:(Da , Electric,
5 Bath Basins _ Heatpump, Other ;p z, (-as
Bath Tubs No. Units Fee
t Showers Furn 000 BTU
j_Hot Water Htr _ Heatpumps
Laundry Washer _ Vent Systems
i 4 Spot Vent Fans P
Sinks o0
� �
Floor Drains No. Boilers/Compressors
F
Laundry Basins — IMP
Dishwasher No. Air Handling Units
Disposal _ cfm#
v Urinals No. Fire Protection Systems
_Other _ Auto. Fire Alarm Sys 50.00
t3 X 3.3s �3•sS _ Fixed Fire Supp. Sys 50.00
Permit Basic Fee 16.75 _ Auto Fire Sprink Sys 35.00
TOTAL PLUMBING $ GO• No. Other
Gas Outlets "
Wood, Gas, Pellet Stove
NOTICE: THIS PERMIT BECOMES NULL AND VOID IF o
WORK OR CONSTRUCTION AUTHORIZED IS NOT COM-
MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee 16.75
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD TOTAL MECHANICAL $ 3'
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 OBTAINING APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING D PARTMENT. DEPARTMENT.
6L �_. ?
X OWNER X BY 1 "'1
[%, "-
DATE �' DATE,.L,2�C I� 2
�
� r
FOR OFFICIAL USE ONLY:Accepted by: Qate:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
L Approval
Planning: 1► !!ill �eJCIS
i
Environmental Health:
1
i
Building Plan Review
g_2Q�-r
Occupancy Group: R-3 Type of Const: sN
Fire Marshal:
Other:
Special Conditions: FEES
((o8ox (f6 = 77, 2 8o Building Permit 50,5• So
Sre4 X L•7-1- 8 0 7 Plan Check 2 SZ 7
a 687 Plumbing Fee (00. 10
Mechanical Fee 9.r
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other HCO re�, 5 00
Other__ Cc
Other
Building Valuation: (, t TOTAL FEE
GARY YANDO,DIRECTOR
srgTF .�
0
M o DEPARTMENT OF COMMUNITY DEVELOPMENT
o N i PLANNING - SOLID WASTE - UTILITIES
7 N Y y BLDG. I • 411 N. 5TH ST. • P.O. BOX 578
SHELTON,WA 98584 • (360) 427-9670
1864
CORD
ILITY: PERMITS ON EXISTING LEGAL LOTS OF RECORD,
DISCLAIMER/WAIVER OF COUNTY LIABILITY:LAND DIVISION APPROVALS, SHORELINE PERMITS, VARIANCES, AND SPECIAL USE PERMIT .S.
The undersigned property owner is aware of the uncertainty regarding Mason County's development regulations created
by the Growth Management Hearings Board's Order of September 6, 1996, and in consideration of Mason County's
willingness to proceed with processing of applications which might be affected by that Order, the undersigned property
owner hereby agrees to waive any lawsuit, action, or claim for damages against Mason County which may arise out of
Mason County's actions in acceptance, processing and/or issuance of such permits or approvals (hereinafter"permitting
actions'), which damages are attributable to the County's decision to take permitting actions despite the risk that changes
to the County's development regulations might later make the County's permitting actions invalid.
Date (Parcel No. or Legal Description)
t c) l
Property o er's signature(Notarized)
(or the County may accept the signature of the owner's authorized agent upon proper proof of authorization)
ACKNOWLEDGEMENT CERTIFICATE (INDIVIDUAL)
STATE OF
COUNTY OF
On this day of in the year , before me Notary Public,
personally appeared personally known to me to be the person whose name is
subscribed to this instrument, and acknowledged that he/she executed it.
WITNESS my hand and official seal. - For County use onJon
Reviewed by applican
(Date)
Notary's signature Staff Initial:
My Commission Expires: