HomeMy WebLinkAboutBLD96-1279 Remodel, Restrooms - BLD Application - 10/15/1996 Permit o. �
MASON COUNTY V)
BUILDING PERMIT APPLICATION �
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
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C41ite Address in w` UI Fire District#
ity 843 41/? —St�_zip 9ce 2�
Directions to Job Site 14wv 3 AA Fqd ol✓ o 4„ eA f= 1; w
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Owner Mailing Address _S�n ce.�r /�;.Z z/,:;,- l�o ,ti3 aJ�
City st be/4 zip C1<s3 $14,�'
Lien/Title Holder C Gt �sr tv
Address Of PO 50k Ys
Clty AeLFAiA St ZG19- zip �4t�'ZSf
#2 Contractor Name Sc 4 Contractor Reg#
Address f 0 I3o� Expiration Date
City l e/4, " St 64- ip Phone#
#3 If septic is located on project site, include records.
Connect to Septic?-4—Public Water Supply Well
Connect to Sewer System? Name of System 6c 4 Plt1A w✓>' T/_= A
(If residential, proof of potable water is required)
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#4 arcel No. /2 3 z - Z 6[�O/�
Legal Description — - 'V -S r-=
#5 Building Square Footage: (existing/ oposed)
1 st FI 3,?,,Pe / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle: Attached or Detached?)
Other sq.ft. /
#6 Use f building /ZZ Describe w rk . Z'Z'o
4100, cow
#7 Type of Job: New 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 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 TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3.25 each) Fee Mechanical Fixtures ($6.50 each)
No. Toilets �3 z SS CIRCLE FUEL TYPE: Gas, Electric,
Bath Basins Heatpump, Other
Bath Tubs No. Units Fees
_Showers 3.� _ Furn BTU
Hot Water Htr _ Heatpumps
_Laundry Washer _ Vent Systems
Sinks 3.2 Spot Vent Fans G
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 16.25 Auto Fire Sprink Sys 35.00
TOTAL PLUMBING $ Z.4.'q 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 FORA 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 DEPARTMENT. DEPARTMENT.
X OWNER X BY
T
DATE lG - / 5- DATE
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Buildinjg Plan Review
Occupancy Group: Type of Const: '
Fire Marshal: 1
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
J
6-05 k
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THPSEANS MUST BE ��
N THE JOB SITE - � ) A d
OR INSPECTION. RAMP `'Qtarl^��'}� rcrtio�c�I Grcc.. I L I
MUST MEET ALL CURRENT
WA HINCTON STATE CODE y
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INVESTIGATION REPORT FORM �'f( p'�I f
Revised 10/6/94
Part A: Nature of Complaint r
• Initiator's Name:
• Address:
• Telephone:
• Owner Name:
• Address:
• Telephone:
• Department of Concern O
❑ Clerical ❑ Building ❑ Health ❑ Comm Development ❑ Fire
• Area of Concern:
❑ Process Delay ❑ Personnel ❑ Policy/Fee ❑ Code Violation ❑ Other
Refer to Director .
• Location f Co cexn:
-1 r✓ M
• 7PXeco
cern:
Part B: Concern Intake and Referral
ed By: Referred To: Response Date:
�d
Name Date Name Date Date
Part C: Findings
Referral Forwarded to: ❑N/A
Name Date
Findings: A b,-_ r < <<11cJ' c mac,f�c c s i
Je-'f 1 6-r\4 UN L-. i< _cr 6-poi t e.g��,J h
T ,
Part D: Resolution
Name Date
Intake Copy-White File Copy-Yellow Referral Copy-Pink