HomeMy WebLinkAboutBLD97-0882 Cancelled Remodel - BLD Application - 7/24/1997 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION q�ib
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9 70/1-800-562-5628 �� �� �
4SE PRIN
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#1 Owner C hone# 6�) (o Z-L -9 74-0 eLO�r7 2¢1,
Site Address .�, p Fire District#
y St W Zip 98521E
Dir tions to Job Site
Owner Mailin Address Q (o
city J St _zip
Lien/Title Holder p
Address
Clty St Zip
#2 Contractor Name 00 Contractor Reg# G l
Address 3$
�� Expiration Date O( / 0-5-
City U c Jk St Phone#Z4-2-Y)�
#3 If septic is located on proje6tite, in de records.
Connect to Septic? ublic ate Supply Well
Connect to Sewer Syst Name f System
(If residential, f o ble ater is requi d)
#4 arc o. Coo
egal Description - '
#5 Building Square Footag (existing/proposed)��p �>
1 st FI �5 hj�o/ I (0 2nd FI —7 3rd FI / Loft r-f
Basement / Deck --/ #be ooms —/ #bathrooms
3arage / Carport / (Circle: ttached or Detached?)
Other sq. ft. T
#6 Use of building Describe wor
#7 Type of Job: ew 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
Plumbing Fixtures ($3 35 each) Fee Mechanical Fixtures ($6 75 each)
No. _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 16.75 _ 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 16.75
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 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 PP OVAL FROM THE BUILDING
THE BUILDING DEPARTMENT. DEPA
X ' ''VNER X BY E ��
DATE DATE—
FOR OFFICIAL USE ONLY: Accepted by: Date:
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 Indicate Directional by (N, S, E, W)
Name of Flanking Street in relation to plot plan
Name of Fronting Street
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
1
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health: i
Building Plan Review
4�1 Z
Occupancy Group: Type of Const:
Fire Marshal:
Other:
FEES
Special Conditions:
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other �-H
Other
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