HomeMy WebLinkAboutBLD93-1367 Cancelled Mobile Home - BLD Application - 9/1/1993 t oU
MASON COUNTY \ ��
MTV' &
BUILDING PERMIT APPLICATIO AUG 3 0 1"3
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT GENERAL SERVICES:
#1 Owner e.� V ,� .� 1 e_ r 2- Phone Zo(o 9,57`,56 y (-- 7 1 / 9
Site Address 1-n 4 r7 Lf ! a W o. Fire District#
City IE2 I -�,- i Stw_Zip 85a 8
Directions to Job Site 150,3• Koo�d a K 50 n3
5 � per Cou She-Ca oa Piro,,o �U
Owner Mailing Address 0 , p/X sa $
City n I o.- ) 1 Q St Wi�q zip 9 9,359
Lien/Title Holder fu f A
Address
Clty St Zip
#2 Contractor Name S rQ c4 , d Co ractor Reg# Mc&CDA*08'8R1'
Address a S Ex iration Date l z l / 7 /
City n I o.. '::'1 ?3 5 9 Phone# 9517-5G y 9'
#3 If septic is located on project site, includfe
Connect to Septic? � Public WaterWell
Connect to Sewer S stem? N O Nam
(If residential, proof of potable water is r
#4 Parcel No. Z 30 -� -
Legal Description L.o f a J 5 e_ 166.
#5 Building Square Footag (exists /propos )
1st FI 1 i 5 Z / 2nd / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other sq. ft. /
#6 Use of building ,.-j4o, use_ 1 e Describe work �S�
1\J fA-1- U �
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION W F Nast ct55eok L -IrS �N SPec4io.�:
O ��w
Model Year l l to Make moors Model
Length L! I? Width Z y Serial No. F X 18D 2�5
#Bedrooms Z #Bathrooms Z- Type of Heat G,45 Gu f_Ny_ r_e
Purchase Price $ 4f S' ODD. oO
#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 /Uorj L
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 Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
i h
ZVI
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0
• N MoQl.i MuMt. � )
� 4L,167,k
� PP;mpty L ~
C
V 1�RAw1FL J ft
3
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A
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
y3P
Plumbing Fixtures ($3 each) fm Mechanical Fixtures ($6 each)
No. '? Toilets Cf CIRCLE FUEL TYPE: Gas Electric,
Z. Bath Basins Heatpump, Other
Bath Tubs No. Units Fees
Showers Furn J�BTU `0
Hot Water Htr / _ Heatpumps
Laundry Washer / Vent Systems
Sinks Spo ent Fans
Floor Drains N Boilers/Compressors
d Laundry Basins HP
Dishwasher No.. Air Handling Units
Disposal cfm#
C' Urinals Fire Protection Systems
—Otheri'" 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 $ 1' 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 15.00
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 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 PA T ENT. DEPARTMENT.
X OWNER X BY
DATE DATE r1
FOR OFFICIAL USE ONLY: Accepted by: t �' - Date: .� (
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
\ S� Approved Cond. Hold
�t— Approval
Planning: �(aS� � 61 1�. GCe� f&W 42Yo Qi i�:)
1 ^. Vol V*S
Environmental Health:
Building Plan Review-TOO,rm�- Pee wAC- -.2 t 6 IS-10
(huS1 M8jA1T*iN m +N 567- BRe,K rs l SLr)aG- &S
►�JeI' 64-r . /s lee cT i oPIJ
Occupancy Group: OLESl LC-Type of Const:
Fire Marshal:
Other:
Special Conditions:
FEES
Dad 5+Oy¢. +--> be, re n-n tecC Building Permit
bN owne4- oew- L 4T- Plan Check
i ns�ec-t�on /a i+erat-la r�
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other
Other
Building Valuation: TOTAL FEE b�.�b
-- r-
Department of Labor&Industries __ ALTERATION PERMIT
Factory Assembled Structures Section ~
Do not complete shaded areas
INSTRUCTIONS: ermit 2
1. Complete all spaces to and including the box with the signature X In It. 3464
2. Draw map on reverse side of WHITE copy only. Invoice#
3. Submit completed permit and fee to the nearest office listed on the back.
4. Contact and schedule the inspection with the office In which you submitted the permit lnstytna�k
within 15 days.
Owner last name first name Day time phone Date
... ...MUIN............................................... . .c )
Address City state ZIP
10310 Qrchard avP SF 011a1a Wa. 98359
Installer/ContractorMealer ?none..
hone Contractors registration number
......................._..............--.......................---.....................................................................................................................................................................................................
Address City State ZIP+4
Check the appropriate boxes In section A and section B. FEES
A ❑ Commercial Coach B ( Alteration Inspection(check appropriate boxes below) $75.00
3anal No. Air Conditioning/Heat Pump
- Electrical �/' C��Cl-c7 3�'%- " "►
Electrical Appliances
Mobile Home Fire Safety
Senal hla; Gas Furnace
Gas Piping
HUD No. Plumbing
Structural
Serial No.
Recreational Vehicle or ❑ Park Trailer Wood/Pellet Stove - - I-,
Serial No:> Plan Review _ __ __ __ _ _ _ _ _ _ _ _ _ _ _. $70.00
RV Inspection - -- - - -- - - $70.00
Model No.or Plan Approval No. Re-Inspection —— —_ Nogtna errntt $50.00
Technical Inspection - -- - _ -- - - _ _ _ $50.00/hr
Signature of applicant or authorized representative Make check payable to: Dept.of Labor&Industries
X FEES DUE $
;trpnent Y
tagnleet approved or Regne>ti denied tiecattee pi'!.S1W'tic violations of V(t.I ggton rules anti reguiatiope Violations
multi ! 00 reeke a1wd >r�ta pas*tiaa gtre tell w thin XO dtiylt for reerestio>tMak`fie tkh" a►ad b iiay for mtii fill tt niies ai d
cometrciaE;tYmcl x►f"t6ei►utltaei'v1Wa#iot�date.;t'I'hisdoea trot"apply to technical h>tspections�: It Is unlawful to offer for sale;
rent,or IeaS ;th+1d g#+iati ilttibil!borne,commercial Bch or recrea.00 l`rel ic(e.
Groff., W.? . ° '. ". !o . ?_lamt y .r
.. t .
Included are forms required which must be completed end f*Submitted befog rcirtspection.��
D a office Total pages
F622-012-W alteration permit 12-92 White-Olympia een-Contractor Canary-Inspector Pink-Purchaser Goldenrod-Purchaser