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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 FRAMING by date by date by
Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
(groundwork Attic
date by date by
D.W.V. WALLBOARD NAILING
date by date by
Water Line FINAL INSPECTION
date by date by I date by
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CONCRETE MECHANICAL ' MOBILE HOME
Footings-Setback date by Ribbons
date by Gas Piping date b
Foundation Walls
date b date by Set Up ��� ��� ��
y INSULATION ; date by
BG/SLAB Insulation Floors `r� Final
date FRAMING by date by `i date by
Walls FIRE DEPT.
date by date by date by
PLUMBING OTHER
Groundwork Attic
date by
date b
D.W.V. WALLBOARD NAILING
date by date ,/by
Water Line FINAL INSPECTION
date by date „1 I�J .-� by `%; /'—c date by
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Permit No.BLD -/ —D.I ate-
MASON COUNTY
BUILDING PERMIT APPLICATION
PLEASE PRINT
#1 Owner �knaC" �- f 41?s o(\J S Phone#(�2C6) LJ D3 1� :23
Site Address LAJ 50 LJE L0 Q F
City fk-. Sta GtJ __Zip
Directions to Job Site Cc p C
r A) ro
Owner Mailing Address C) t a-
City 14 CUC705 P0(2-:\— St e Wfl: Zip 4Zels ly
Lien/Title Holder Me-A-U 1 N -
Address QE1Q--- Ul><} Q-- 4-4
City 45-eO?/5DACE State a/Z«/UR Zip
#2 Contractor Name &I � Contractor Reg #
Address Expiration Date
City State Zip Phone
#3 If septic is located on project site, include records .
Connect to Septic? Public Water Supply W 11
(If residential, proof o potable 4t rT
be re ired�,.
- c
4
#4 Parcel No. -
Legal Description
#5 Building Square Footage: (existing/proposed) 4
1st F1 � / ireck
nd -� / 3rd F1 Loft /
Basement / #Bedrooms / #Bathrooms /
Garage Carport / (Circle: Attached or Detached?)
Other sq ft /
#6 Use of buildin Describe work ZMAD k&W-1'
#7 Type of Job: New Add Alt Repair Demolition
_ Re-roof Bulkhead Other
L-U-'1`
#8 -Mobile Home Information 'm L) L4 L 1 N 6
Model Year Eq3 Make ra , Model A'e' 0 fy)DYZ.�L
Length yt Width : 5� Serial No. - 1 '9 3 5 _
#Bedrooms #Bathrooms Type of Heat J CC" ti 1�-
Yf 7-5
#9 Any water on or adjacent to property: Saltwater Lake River
Pond Wetland Seasonal runoff Other
Show tallow mcr on the site plan
Trot Dimensions ;Flood Zones
Existing Structures ;Fences
Structure Setbacks Driveways;
Water Lines Shorelines :
Drainage an. Topography
Septic System Wells
Proposed Improvements< Easements:
Name of Flanking. Street Scale:.
Name of Fronting Street
� 'Date
APPLICANT TO DRAW SITE PLAN BELOW
T,,.
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APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Fixtures ($2 . 00 each) Fee: No. Boilers/Compressor Fees:
;Toilets 0-3 HP 6.00
Bath Basins 3-15 HP 6.00
Bath Tubs 15-30 HP 6.00
Showers 30-50 HP 6.00
Hot Water Htr "moo + HP 6.00
Laundry Washer N\
Sinks Air\Handling Unit
Floor Drains - 1000 cfm. 7.50
Laundry Basins 10, 000 cfm. 7.50
Dishwasher
Disposal ther
Urinals vap Coolers
Other -Hoods
ire Suppression
Permit Basic Fee .00 omes. Incin.
TOTAL PLUMBING $ omml . Incin.
eloc/Repair 6.00
Mechanical Fixtures as Outlets x 2 . 00
No. Fuel Types oodstove separate
Furn < 100K B 6.00 ther_
Furn >= 110 BTU 6.00
Furn - oor 6.00 Perm t Basic Fee 10.00
Heat amps 6.00 TOAL MECHANICAL $
V t System x 3 . 00
Vent Fans x 3 .00
f.
..
NOTICE THIS PERMIT BECOMES NQI A= VOID IF WORD; OIL CONSTRUCT.IQN
.
AUTHORIZED. 'IS NOT COMMENCED WITHIN 1$0 DAYS, O IF CONSTRUCTIOIOR WORK I5
SIIPENDLD OR ABANDONED ................ A >PERI'OD :::OF::,.,.l$f� DAY AT ANY TIMH AFTER WORR xS
COMMENCED.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I certify that I am exempt from the requirements of the 1 certify that 1 am a currently registered contractor in
contractors registration law RCW 18.27 , and am the State of Washington and I am aware of the
aware of the Mason County Ordinance requirements for ordinance requirements regulating the work for which
which this permit is issued and that all work done will the permit is issued and all work done will be in
be in conformance therewith. No changes shall be conformance therewith. No changes shall be made
made without first obtaining approval from the Building without first obtaining approval from the Building
Department. Department.
X OWNER X BY
DATE: 2 - - _:3 DATE
Return permit to: Department of General Services 426 W. Cedar Street/P.O. Box 186
Shelton, WA 98584 427-9670/1-800-562- 638
r {
FOR OFF'>`CxAL USE ONLY Accepted by � Date �<
PV
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
App—i Cod Aoa
App—d
Planning:
Environmental Health: pi- tr-to t i
i
i Building Plan Review: i
L�l-Ct
Occupancy Group:
Fire Marshall:
i
i
Other:
FEES
Special Conditions:
Site Inspection
Buildinq Permit
0
Violation Fee
Violation Investigation Fee
Plan Check
Plumbing Fee
Mechanical Fee
Woodstove Fee
Building State Fee
Building Valuation
TOTAL ,
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