HomeMy WebLinkAboutBLD N/A Deck - BLD Application - 1/12/1996 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION qbU74
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 l�l ` ��'� ' OF6
PLEASE PRINT
#1 Owner Phone# 2-� -5 33-7
Site Address -Z`�o Fire District# S
City _UU L�Cu c� \1Jc, - St \-J Zip
Directions to Job Site "'�- �``��^ V a'^
c .,� 2-YI.1 ..T
Owner Mailing Address lPy _Lx-�
City _ e3 - St �G Zip 585Z�
Lien/Title Holder
Address
Clty St Zip
#2 Contractor Name ��o� ���^ C o�S. Sic - Contractor Reg #
Address Expiration Date
city St fib- Zip Phone# 30� 2'ts- 533'7
#3 If septic is located on project site lude records.
Connect to Septic? ublic Water Supply ell
Connect to Se ystem? Na System
(If res' ial, proof of pot ble er is required)
\Z330 - 0o ozy
#4 Parcel No. -
Legal Description
#5 Building Square Footage: (existing/propo
1st FI / 2nd FI / �d / Loft /
Basement / ck #b rooms / #bathrooms /
Garage / Car ort CSUZ (Ci le: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 Make el
Length Width Serial No.
# Bedrooms # Bathrooms ype of Heat
Purc 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 Runo t r
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
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3-�ach) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bat Basins Heatpump, Other
Bath Tu No. Units Fees
Showers Furn BTU
Hot Water Htr _ Heat ps
_Laundry Washer _ ent Systems
_Sinks Spot Vent Fans
Floor Drains No. Boilers/Compressors
_Laundry Basins _ HP
Dishwasher No. Air Handling
_Disposal cfm#
_Urinals No. Fire Protection Systems
Other \ Auto. Fire Alarm Sys 50.00
Fixed Fire Supp. Sys 50.00
Permit Basic Fee 15.00 _ Auto Fire Sprink Sys 25.00
TOTAL PLUM G $ No. hPr
Gas Outlets
Wood, Gas, Pellet Stove
/NOTICE: S PERMIT BECOMES NULL AND VOID IF
NSTRUCTION AUTHORIZED IS NOT COM-
HIN 180 DAYS OR IF CONSTRUCTION OR Permit Basic Fee 15.00
PENDED OR ABANDONED FOR A PERIODTOTAL MECHANICAL $
S 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 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 -y
DATE DATE V \—L_c'J(C)
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW •
- FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review
Occupancy Group: Type of Const:
Fire Marshal:
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