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HomeMy WebLinkAboutBLD93-1423 ATF Repairs, Addition - BLD Application - 9/8/1993 Permit No. MASON COUNTY BUILDING PERMIT APPLICATION 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 0q A PL A E PRINT � #1 Owner D l ` Phone# a 7 �- -;2 6 6 7 Site Address N jeCL FA/P2 ljtxJl, CL,-A/4 lk-,J cl- Fir District# City L / St !� zipC/F 8 Directions to Job Site ©LD Q�GFf�I� <x)�/ To A/E /�6 Z- Tu P-A; t70-W Ai D 1Z I ✓MA y To 6Nb Owner ailing Address P 0. City )061-F4/lam St Zip �J L Lien/Title Holder f a Address Clty St Zip #2 Contractor Name G _ 1 Contractor Reg# Address Expiration Date City St Zip Phone# If septic is located on project site, include records. Connect to Septic? Public Water Supply Well -5He6(-,W .- Connect to Sewer System? Name of System (If residential, proof of potable water its required) #4 Parcel No. ' 04Pa Legal Description 12 (o of /V IZ. /VW A16 #5 Building Square Footage: (existing/proposed 1st FI i (� 2nd FI / 3rd FI / Loft / Basement / Deck }/�/ - #bedrooms / #bathrooms / Garage / Carport / (Circle: Attached or Detached?) Other sq. ft. / #6 Use of building Describe work #7 Type of Job: New Add _Alt Repair Other #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year e Model Length q47Bathlroomserial No. # Bedrooms Type of Heat Purchase Price$ #9 is by circ icable source if any water is on or adjacent to subject property: ' „Rior on Creek Stre Wetland Lake Marsh Saltwater Seasonal Runoff Other G v_ 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 SIT LOW I ,vvcK V9 LlI IJ� APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each) N Toilets CIRCLE FUEL TYPE: Gas, Electric, ath Basins Heatpump, Other i _Bath Tubs No. U nit Fees Showers Fur 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 Fire Protection Systems Other Auto. Fire Alarm Sys 50.00 Fix Fire Supp. Sys 50.00 Permit Basic Fee 15.00 Auto Fi Sprink Sys 25.00 TOTAL PLUMBING $ No.. Other Gas Outlets Wood, Gas, Pellet S ve 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- MENCED. PROOF OF CONTINUATION OF WORK IS BY MEANS OF A PROGRESS INSPECTION. O NERS 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 DEPARTMENT. DEPARTMENT. X OWNER ��� X BY DATE 9—75,-- DATE FOR OFFICIAL USE ONLY:Accepted by: Date:. DEPARTMENTAL REVIEW FOR OFFICE USE ONLY -[Approved Cond. Hold Approval Planning: Environmental Health: Building Plan Review C,Q ll Occupancy Group: Type of Const: Fire Marshal: Other: Special Conditions: FEES Building Permit $p O o Plan Check Plumbing Fee Mechanical Fee Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee 4 Other e Other Building Valuation: AM 0��f �1 ec �L cf�j'fA TOTAL FEE t 53w) S31Y1S N019NMSVM iN3bbt1) IIV 133W 1SnW 0 C2 a INVESTIGATION REPORT FORM Revised 6/3/93 Part A: Nature of Complaint • Initiator's Name: d�7017tIV222 • Address: • Telephone: • Owner Name: • Address: • Telephone: • Department of Concern ❑ Clerical Building ❑ Health U Comm Development ❑ Fire • Area of Concern: ❑ Process Delay ❑ Personnel ❑ Policy/Fee ❑ Code Violation ❑ Other Refert ect _ • Location of Concern: r v� • Nature of Concern: `1 Part B: Concern Intake and Referral Received By- �,. Referred To: Response Date: C:A Name Date Name Date Date Part C: Findings Referral Forwarded to: ❑N/A Name F\ Date Findings: 2, 75-- 2K,4�,7 . a � e JoL&,C(, i h ' o f $P�. f• h +s 1f Part D: Resolution 9-7-13 1- Name Date Intake/File Copy-White Referral Copy-Yellow Referral Copy-Pink Tracking Copy-Gold