HomeMy WebLinkAboutBLD98-00125 TPN42001-44-90001 - BLD Application - 2/13/1998 �t-n98- o I a5
Permit c p�''
MASON COUNTY �
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670 Q
(Calling From Seattle 464-6968, Belfair 275-4467, Elma 482-5269)
PLEASE PRINT
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#1 O ner L Phone# -��
ite Address Fire District#
City 611111 St /,_.�'I Zip
Directions to Job Site 1 l % ✓ ^i -�� ,cam
Owner Mailing Address
City St Zip
Lien/Title Holder
Address
City St Zip
#2 Contractor Name IV ,VL UBI #
Address 60 4?1Contractor Reg#/4�Ln�ti �S Z
City S'f�f��f/ St Zip��B 9 Phone Expiration Date
#3 If septic is located on pro t site, include records. /
Connect to Septic?Public Water Supply Well V
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 rcel No. o V
L gal Description +- ♦ Exl (Q
#5 Building Square Fo t ge:
1st FI , 2nd FI 3rd FI Loft Basement
# Bedrooms # bathrooms Deck Other
Garage j� Carport (Circle: Attached or Detached?)
#6 Use of buildings / Describe work ft/ /ill
u
#7 Type of Job: New Add Alt Repair
#8 MOBILE/MANUFACTURED HOME INFORMATION D
r
Model Year Make Model
I Length Width Serial No.
# Bedrooms # Bathrooms Type of Heat PERMIT ASSISTANCE CENTER
Purchase Price$ 'a
#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 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)
in relation to plot pla
Name of Fronting Street n
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3.45 each) Fee Mechanical Fixtures ($7.00 eachl
No._Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
_Bath Tubs No. Units Fees
_Showers Furn BTU
_Hot Water Htr _ Heatpumps
_Laundry Washer _ Vent Systems
_Sinks _ Spot Vent Fans
Floor Drains No. Boilers/Compressors
iLaundry 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 17.25 _ Auto Fire Sprink Sys 35.00
TOTAL PLUMBING No. Other
Gas Outlets
Wood, Gas, Pellet Stove
NOTICE: THIS PERMIT BECOMES NULL AND VOID IF _
WORK OR CONSTRUCTION AUTHORIZED I I PNOTCOM-
MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee 17.25
WORK IS SUSPENDED OR ABANDONED FORA 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 OFTHE ORDINANCE REQUIREMENTS REGU-
ORDINANCE REQUIREMENTS FOR WHICF 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 APPROYAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTMENT.
I X OWNER X BY
DATE
DATE
FOR OFFICIAL USE ONLY: Accepted by: ; Date;
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
� r4fZCEL LAG '-
Building Plan Review�lKSrPRSIUKLS�2 S`�STEI`-1 (�Cit ► cRFf1
Occupancy Group: Type of Const:
Fire Marshal:
Other:
k
FEES
Special Conditions:
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other
Other
Other
Building Valuation: TOTAL FEE