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MASON COUNTY Permit No.
BUILDING PERMIT APPLICATION PLEASE PRINT V� I
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 _ �1 k(o
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#1 eite
r
Phone#o
ddress 9/
City 1 , Fire District# /(p
Directions to Job Site Qy�,J / St _Zip 98s�y
/77 s
a4/5
Owner Mailing Address .Y, P
City
Lien/Title Holder St Zip
Address
City
St Zip
#2 Contractor Name�,_-Ta� /ieo,5 f 6/V 57`
Address/�!/9k� s��� �f j Contractor Reg# �i¢� /_�S��y�
City ��j e-A/d� Expiration Date / /
St- _Zip_ ZE: y Phone
#3 If septic is located on project site, include records.
Connect to Septic? ✓ Public Water Supply Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 Parcel No--rid e 1
01 egal Description
�jL I D-� 6 !Su r U ' 88
#5 Building Square Footage: (existing/proposed) 75
1 st FI l�a�r 2nd FI
/1/ 7-' Basement /-- -13� 3rd FI / Loft /
fj / Deck / #bedrooms l 1. #bathrooms /
Garage / Carport / �.
(Circle:Attached or Detached?)
Other sq. ft. /
#6 Use of building� a-lav»P61
a
NDescribe work,Q� �
#7 Type of Job: New__Add__Alt__Repair
#8 MOBILE/MANUFACTURED HOME
INFORMATION �1 ,
Model Year Make Model 1 7 1
Length Width Serial No.
--
# Bedrooms # Bathrooms
Purchase Price$ Type of Heat EALL I HERVIC��,
#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 Flood Zones
Existing Structures Fences
Structure Setbacks Driveways
Water Lines Shorelines
Drainage Plan Topography
Septic Systems Wells
Proposed Improvements Easements Indicate Directional by (N, S, E, W)
Name of Flanking Street in relation to plot plan
Name of Fronting Street
APPLICANT TO DRAW SITE PLAN BELOW
G/v
U�
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures-($ 'ea hl F Mechanical Fixtures ( 6•ea
achl
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
,Z-Bath Basins l . Heatpump, Other
Bath Tubs So. No. _UaL Fees
Showers _ Furn BTU
% Hot Water Htr _ _ Heatpumps
Laundry Washer _ Vent Systems
_Sinks Spot Vent Fans 13.00
Floor Drains No. Boilers/Compressors
Laundry 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 15_00 Auto Fire Sprink Sys 25.00
O
TOTAL PLUMBING S No. Other
Gas Outlets
T�'Wood, Gas, Pellet Stove �Z.�
NOTICE: THIS PERMIT BECOMES NULL AND VOID IF
WORK OR CONSTRUCTION AUTHORIZED IS NOT COM-
MENCED WITHIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee „X5.A0
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD
OF 180 DAYS AT ANY TIME AFTER WORK IS COM- TOTAL MECHANICAL
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 OF THE 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 DEPARTMENT. DEPARTMENT.
X OWNER X BY
DATE DATE
FOR OFFICIAL USE ONLY:Acceptetl by. Date: / �
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
i
Environmental Health:
Building Plan Review
I
1� S'
Occupancy Group: Can, Type of Const: 5
Fire Marshal:
Other:
FEES
Special Conditions:
+{cad Y Soo Building Permit
Plan Check 22?
Plumbing Fee �($
Mechanical Fee fig•
0
ood/ s/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee 44,
Other
Other
Building Valuation: °` `�F TOTAL FEE a
GARY YANDO,DIRECTOR
STgrFO
M o q DEPARTMENT OF COMMUNITY DEVELOPMENT
A� =
0 T i PLANNING —SOLID WASTE—UTILITIES
N Y Y BLDG. I • 411 N. 5TH ST. 9 P.O. BOX 578
1864 SHELTON,WA 98584 • (360) 427-9670
DISCLAIIIZER/WAIVER OF COUNTY LIABILITY:PERMITS ON EXISTING LEGAL LOTS OF RECORD,
LAND DIVISION APPROVALS, SHORELINE PERMITS, VARIANCES, AND SPECIAL USE PERMITS:
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)
operty owner's tune(Notariz )
(or the County may accept the signature of the owner's authorized agent upon proper proof of fin)
�\ST/N,` %a
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Ho �0
ACKNOWLEDGEMENT CERTIFICATE(INDIVIDUAL) M i
8 STATE OF �.S 9••°•° �'.•
'16)11NG10\4 }I
COUNTY OF
On this day of , in the year_q�4,before me Notary Public,
personally appeared OYL-)`4 z- 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 only-
Reviewed by plicant on
(Date)
Notary's signature
My Commission Expires: L— Staff Initial:
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