HomeMy WebLinkAboutBLD94-0048 SFR - BLD Application - 1/14/1994 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION q,1 .
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 ` P
PLEASE PRINT `
#1 Owner J/ , STt'I 1,fZc,�2 6- Phone# 2-"7 - FiSL
Site Address t-- 9 D :D8IX-If� t„ kq Fire District#
City S L1-C,&a1hJ St W,_Zip 'cf kSTU
Directions to Job Site /y14.1>o 1 (,.A-Kk RA ZT RA i 4a)Zr?/4'2v aa.2
'p<I' (5 arJ RT
Owner Mailing Address Q C�
City -�'k' ---r St L JA- _Zip R8S'TM
Lien/Title Holder NN2
—o-
Address
Clty St Zip
#2 Contractor Name S ��i�,�]c_2,< Contractor Reg#-�K;?Vi x*-
Address n -0 `I��c 1 I Expiration Date
City Sj 4,�,,-t,�) St C'h� Zip 01g-5 Phone# Z-7 &/ g'6
#3 If septic is located on project site, include records.
Connect to Septic?_,)(' Public Water Supply X Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 Parcel No.'32 12'1 - '�V - 6o I!1t
Legal Description '-!c I- I NZ W4 e'g le'k piyl
#5 Building Square Footage: (existing/proposed)
1st FI / )!�Lj< 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / 3 #bathrooms / Z
Garage / yob Carport / (Circle: ttach or Detached?)
Other sq. ft. /
#6 Use of building S Describe work
#7 Type of Job: Newer Add 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 J Flood Zones
Existing Structures Fences N) 5
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 I 3
0
NJ
1
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APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Z 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
_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
TOTAL PLUMBING $ _ No. Other
Gas Outlets
Wood, Gas, 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- 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 OBTAININ APPROVAL__F-ROM THE BUILDING
THE BUILDING DEPARTMENT. DEPARTM - -R
X OWNER X BY
DATE DATE /_
I
FOR OFFICIAL USE ONLY:Accepted by: Date:
!` I
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review
Occupancy Group:.tZ-3 ype of Const: 5'-(V
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit 30.6b
Plan Check 1.50
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor ,(�
Violation Fee
Site Inspection
Building State Fee y 50
Other
Other
Building Valuation: (0I Op TOTAL FEE (� 5. (v