HomeMy WebLinkAboutBLD94-0342 Cancelled Mobile Home - BLD Application - 3/18/1994 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 �'
PLEASE PRINT
#1 Owner1Z1111e-- ro1r, - Se_Q"'Ar Q4 Phone# 2 G 3 ?
Site AddreW P 90 O c✓ ek �*c h Fire District#
City 1N v!/'cz 5 St 4V Zip Q$b' 2 8
Directions to Job Site
Owner Mailing Address 37�C -esl� e�y �A � -
City 5 A,:e, -eA fm h / St a Zip? 83(71
Lien/Title Holder
Address
Clty St Zip
#2 Contractor Name lam'S 4 (c- T, oa'V c Contractor Reg
Address 0C Expiration Date
City e4 St -C Zip Z if5/2, Phone#
#3 If septic is located on project site, include records.
Connect to Septic?_X—Public Water Supply Well X
Connect to Sewer System? Name of System
(If residential, proof of potable water is re uired)
#4 Parcel No 3 -�a - "V- ! O
Legal Description i T �a
9 P
#5 Building Square Footage: (existing/proposed)
1 st FI / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle: Attached or Detached?)
Other sq. ft. /
#6 Use of building ��� Describe work OS/L.. :
#7 Type of Job: Newer__Add Alt Repair Other
4
#8 MOBILE/MANUFACTURED HOME INFORMATION � r�� .
ni�
Model Year Zff 7 7 Makes Model _
1994
Length 70 . Widths Serial No. )VS S`7 g 7 8
# Bedrooms / # Bathrooms oZ Type of Heat (71
Purchase Price$ 1$/O,dk::16
#9 1pdicate 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
r
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 T D P OF BELOW
l II
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
•No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
Bath Basins Heatpump, Other
Bath Tubs No. Unita des
Showers _ Furn BTU
Hot Water Htr — Heatpumps
—Laundry a b We\ _ 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.
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 TOTAL MECHANICAL $
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 D PARTMENT. DEPARTMENT. �—
X OWNER X BY C ?� l• ��- -
DATE // / DATE
FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review mP e c S , M H LKN C,%IN�i _ o a5% ftD2. 5-5
W
Occupancy Group:2-3 Type of Const: SN
Fire Marshal:
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 l0
i