HomeMy WebLinkAboutBLD98-0708 SFR Repair - BLD Application - 7/16/1998 PERMIT NO : BLD - 7 O D
MASON COUNTY
BUILDING PERMIT APPLICATION -7-c-7M
426 W.Cedar/P.O.Box 186,Shelton,WA 98584
Shelton 360 427-9670 Belfair 360 275-4467 Elma 360 482-5269 Seattle 206 464-6968
APPLICANT INFORMATION CONTRACTOR INFORMATION
Owner t Contractor Name Ohl ST KE -
Mailing Addres Mailing Address
City `'t State Zip Code City State Zip Code
Phone( °' "Other Ph.( Ph.(_ 1 Other Ph.
Lien/Title Holder Contractor Reg. # �'
Address Expiration
SEPTIC/WATER SYSTEM INFORMATION-Connect to New Septic Existing Septic Connect to Sewer
System Name of Sewer System Well Water System Name of
Water System
PARCEL INFORMATION-12 digit Tax Parcel No., Fire District
Legal Description 'tt f I1"
Site Address(Please include street name, street number and city)
Directions to site Vy E
Will timber be cut and sold in parcel preparation? (Yes/No)
Is your property within 200' of the following: Body of Water (Name) Saltwater
Lake River/Creek Pond Wetland Seasonal Runoff Stream Slopes or
Bluffs
TYPE OF JOB New Adder Alt Repairs_ Other T Use o_f Building
Describe Work
No. of Bedrooms No. of Bathrooms SQUARE FOOTAGE-1st Floor 2nd Floor
3rd Floor Loft Basement Deck Garage Carport
Other sq. ft.
MOBILE HOME INFORMATION-Make Model Model Year
Length Width Serial No. No. of Bedrooms No. of Bathrooms
Type of Heat Purchase Price $ Replacement Unit ?(Yes/No)
Installer Name Certification No.
NOTICE: THIS PERMIT BECOMES NULL&VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS OR IF
CONSTRUCTION WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER THE WORK IS COMMENCED.
PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. The owner or agent on owner's behalf,represents that the
information provided is accurate and grants employees of Mason County access to the above described property and structures for review and
inspection of this project. Acknowledgment of such is by signature below:
OWNER AFFIDAVIT-I certify that I am exempt from the requirements of the CONTRACTOR'S AFFIDAVIT-I certify that I am currently registered as a
Contractor Registration Law RCW 18.27 and am aware of the ordinance contractor in the State of Washington and that I am aware of the ordinance
requirements for which this permit is issued and that all work will be done in requirements regulating the work for which this permit is issued and all work
conformance therewith. No changes shall be made without first obtaining shall be done in conformance therewith. No changes shall be made without
approval. first obtaining approval.
X Date X Date
FOR OFFICIAL USE BEYOND THIS POINT—
Accepted by Date Submittal Amount Due � ' / D Receipt Norw`
DEPARTMENTAL.REVIEW APPROVED DENIED:' DC3N1RITiG►N Q��Iw�
Building Department
Occ Group Type Constr. `"� ST-
Planning Department
Environmental Health Department
Public Works Department
Fire Marshal
Valuation $ (Ooo
FEES
__ _.._.. ..__..._ ....... .._- __._.._.
Building Permlt Fee 511-oc' Site Inspection
Plan Review Fee o UFC Plan Review Fee
Plumbing & Base Fee Public Works Review Fee
Mechanical & Base Fee Other
Wood/Gas/Pellet Stove Fee Other .
Violation Fee Pre-Paid at Submittal
TOTAL FEES
FORM MUST BE COMPLETED IN INK
PLEASE PRESS HARD MASON COUNTY PROJECT SITE INFORMATION
Case No.
Name W IS PARCEL NUMBER ZZ2-01 Z•Z 901ZQ Date_7• /(,, `q6__
SHOW THE FOLLOWING ON SITE PLAN Show Direction by indicationg N, S, E, W in relation to the
site plan
Lot Dimensions Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Well Location (including adjacent) Drainage Plan
Names of Streets Easements
11 Names of Fronting Streets Septic System
DRAW SITE PLAN BELOW Include adjacent properties if on shoreline or within 100 feet of adjacent property line.
adjacent property line- I I E-adjacent property line
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adjacent property line- I I <—adjacent property line
SAMPLE SITE PLAN
adja�nt property line-� 3>o' _ f-adjacent property line
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TOPOGRAPHY PROFILE(Show a side view of property. Show slopes, cuts and fills. If possible include height and the
degree of slopes. See sample topography profile.)
SAMPLE TOPOGRAPHY PROFILE
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Signature Date