HomeMy WebLinkAboutBLD95-00854 Cancelled Mobile Home and Deck - BLD Application - 8/22/1995 Permit No.
434�
MASON COUNTY
BUILDING PERMIT APPLICATION o�
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 Owner �f G 0 �4'zC-�' Phone#
oAddress i OctG� Fire District#
cizy '-z 1�r/� St Zip
Directions to Job Site
Owner Mailing Address
City St Zip 577EY21L
Lien/Title Holder r zD s
Address C)
City '-o St
#2 Contractor Name ^rn Contra R C2770Ic-
ol
Address E ati / / 9J
City St Zip �#
#3 If septic is located tdede records.
Connect to Septic? Supply Well C
Connect to Sewer e of System r L 4.� �
o 6�
(If residential, p or quired)
f
#4 rc N �Legal scriptionD r �c *C�
#5 Building Sq are Footage (existing/propQsed)
1 st FI l�y l 2nd FIB / 3rd FI / Loft /
Basement / De / #bedrooms-3 / #bathrooms /
Garage / C o / (Circle:Attached or Detached?)
Other L sq.ft. /
#6 Use of building Describe work.
#7 Type"ob: Add Alt Repair Other
#8 MOBILE/ UFACTURED HOME INFORMATION
Model r Make�6 Model
Len Width � Serial No. —
# rooms # Bathrooms 2 Type of Heat C &1r,'L
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 /%
I
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
IT
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 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
_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 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 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 DEPART T. t DEPARTMENT.
/ A.
X OWNER uu X BY
/��-c �7
DATE �> ' DATE 1-2
S
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning: %A41 - S6 "�s Sc e Cr�ndt i 4-1 m s 1 A T M . i7)Ms
G/Z7
Environmental Health:
1-Lt-'t
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 �PLL' Oa
Other
Building Valuation: TOTAL FEE