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CONCRETE MECHANICAL MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls date by Set Up
date by INSULATION date by
BG/SLAB Insulation Floors Final
date by date by date by
FRAMING Walls FIRE DEPT.
date by date date by
PLUMBING Attic by OTHER
Groundwork
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by date by
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Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION p `�
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 0
PLEASE PRINT
#1 /t Phone# �Jz�-9� �,p Cat '►� �
Address w o e'er r1s 41 1 & Fire District#
City �'I..�, l+�ti uJCI St�tZip
Directions to Job Site
.49
Owner Mailing Address
City A St _Zip 'F9S-g-./
Lien/Title Holder e'17
Address
City St Zip
#2 Contractor Name A "�� Contractor Reg#
Address Expiration Date
City fl St Zip Phone#
#3 If septic is located on project site, include records.
Connect to Septic? Public Water Supply Well
Connect to Sewer stem? Name of System
(I residential, proof of potable water Is required)
Parcel No. - -
Legal Description
#5 Building Square Footage: (existing/proposed)
1 st FI / 2nd FI / rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms 1
Garage / Carport / Ircle:Attached or Detached?)
Othe sq. ft.�r
#6 Use of building Describe work
#7 Type of Job: New Adder 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 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
Name of Flanking Street Indicate Directional by (N, S, E, W)
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
E
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
Bath Basins Heatpump, Other.
Bath Tubs No. Units Fees
Showers _ Furn BTU
Hot Wa r Htr _ Heat um s
Laund Washer Ve t ys e
Sinks _ Sp t e t F ns
Flo r in Bo I r Co re
Lau ns �HP
Dish s er No. Air Handling
ni
Disp sal cfm#
Urinals No. Fire Pro io S tem
Other _ Auto Fir Al rm s 50.00
Fix d F' a ys 50.00
Permit Basic Fee 15.00 u o Fi a prin S s 25.00
TOTAL PLUMBING $
Gas O tlets
Wood, as, Pellet Stove
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 15.00
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD
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 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 DEP RT DEPARTMENT.
XO XBY
DATE 2 —/ DATE
FOR OFFICIAL USE ONLY:Accepted by: Date:
a
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold +
Approval
Planning: '
Environmental Health:
Building Plan Review (N
Occupancy Group: Type of Const:
Fire Marshal:
ti
Other:
Special Conditions: FEES
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other
Other
Building Valuation: TOTAL FEE