HomeMy WebLinkAboutBLD96-0553 Cancelled Bridge - BLD Application - 2/5/1999 Permit No. /
MASON COUNTY
BUILDING PERMIT APPLICATION
B� D
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT r /
#1 Owner V �a �` - ���(61Ll5' Phone# 7�V ��
Site �Vlel_p
s� f � l v ''Firre District#
City �(�/' Q St `14 - Zip
Directions to Job Site r g ! �f - B P Te h S e c 7-( o
Owner Mailing Address ti L'
City T-6 G� St Zip 3(
27
Lien/Title Holder
Address
City St Zip
#2 Contractor Name G S !mod f �• Contractor Reg#
Address Expiration Date
City St Zip Phone#
#3 If septic is located o roject site, include re .
Connect to Septic,. Public Water upply Well
Connect to Sewer System? --------Name of System
(If residential, proof of potable water is re ' ed) l�� &ncZq l P_ I
#4 cel No.� 4"
�(sL�r h �3 /
egal Description c •�� Se f�oti ` �'
#5 Building Square Footage: (existing/pro osed)
1st FI / 2nd� / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Ca / (Circle: Attached or Detached?)
Other q•ft. /
#6 Use of building a Describe work ack-05;5
#7 Type of Job: New_ _Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFOPMATION p (� V Do
Model Year Make odel
Length idth Serial No. MAY 13 1996
# Bedrooms # aThhmoms . Type of Heat
Purchase Price $ C
APAI TH SERVICE
#9 Ind' ate 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
� h
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
D ��
Plumbing Fixtures ($3.25 each) Fee Mechanical Fixtures ($6.50 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
Bath Basins Heatpump, Other
Bath Tubs No. Units Fees
Showers _ Furnl BTU
Hot Water Htr _ Heatpumps
_Laundry Washer _ Vent Systems
_Sinks _ Spot Vent Fans
Floor Drains No. Boilers/Compressors
_Laundry Basins HP
_Dishwasher Air Handling Units
_Disposal cfm#
_Urinals No. Fire Protection Systems
Other T A o. Fire Alarm Sys 50.00
Fixed Fire Supp. Sys 50.00
Permit Basic Fee 16.25 _ Auto Fire Sprink Sys 35.00
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 16.25
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 OFTHE 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 EP RTME T. DEPARTMENT.
X OWNER X BY
DATE l DATE
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Ap roval
Planning:
AA AeNf-I
OF q
Environmental Health:
1
Building Plan Review
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit
Plan Check -' Z
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
AW Site Inspection
i Building State Fee
Z-CP. 6 Other
C P Other
Building Valuation: TOTAL FEE