HomeMy WebLinkAboutBLD97-00729 Cancelled Mobile Home - BLD Application - 9/10/1997 V
Permit No.
MASON COUNTY
UILDING PERMIT APPLICATION
S``'426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 Ok �a
(Calling From: Seattle 464-6968, Belfair 275-4467, Elma 482-5269) �u
XPLEASE �\5� 1,ee �,�/7 /Jhi'�5U✓J Phone#ddress ISO ��� hIP ��.�� Fire District#y he-/1-v k14 St k0 zip '!0
Directio o Job Site
Owner Mailing Address ne/ zdke
City St. Gi4 Zip_ Sf5
Lien/Title Holder
Address
City St Zip
#2 Contractor Name Contractor Reg# " JN
Address LF 2 Expiration Date_ 1-_L�.f—/�_
City St /I Zip i-5 Phone# `NO- 'Y34P- "�'3Ol
#3 If septic is located on project site, include records.
Connect to Septic? Public Water Supply Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 Parcel No32Lo'7 -. _- ao//0
Legal Description SO
#5 Building Square Footage:
1st FI 1 2nd FI - 3rd FI - Loft - Basement _
# Bedrooms ,.3 #bathrooms 6L Deck Other
Garage - Carport - (Circle:Attached or Detached?)
#6 Use of building Q&I P- Describe work o e-�
#7 Type of Job: New _Add Alt Repair Other
#8 MOBILE/MANUFACTURED H_QN E IN ORMATION
Model Year q7 Make���� t Model 115f3w
Length Width 22� Serial No.
#Bedrooms _# Bathrooms Type of Heat ,!5-�,,e,
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 Fences
Existing Structures Driveways
Structure Setbacks Shorelines
Water Lines Topography
Drainage Plan Wells
Septic Systems Easements
Proposed Improvements
Name of Side Street Indicate Directional by (N, S, E, W)
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
110
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Zr�N
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W Se rvc.
OulArtr hook-,;t;-
.110 ' --->
471 0r
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
i
15�
15 �
2'A) qn'
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-
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
DATE DATE 9 7
FOR OFFICIAL USE ONLY: Accepted by: Date: �"J`
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning: CV/1 g
Environmental Health:
Building Plan Review
Occupancy Group: Type of Const:
Fire Marshal:
i
Other:
Special Conditions: FEES
Building Permit
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Violation Fee
Site Inspection
Building State Fee
Other
Other
Other
Building Valuation: TOTAL FEE
I
GARY YANDO,DIRECTOR
PyON.STgTFo
A v �, DEPARTMENT OF COMMUNITY DEVELOPMENT
O T Z PLANNING - SOLID WASTE - UTILITIES
N Y y BLDG. I . 411 N. 5TH ST. • P.O. BOX 578
of 1864 �0 SHELTON,WA 98584 • (360) 427-9670
DISCLApgER/WAIVER OF COUNTY LIABILITY:PERMITS ON EXISTING LEGAL LOTS OF RECORD,
LAND DIVISION APPROVALS, SHORELINE PERMITS, VARIANCES,AND SPECIAL USE PERMITS:
The undersigned property owner is aware of the uncertainty regarding Mason County's development regulations created
by the Growth Management Hearings Board's Order of September 6, 1996, and in consideration of Mason County's
willingness to proceed with processing of applications which might be affected by that Order, the undersigned property
owner hereby agrees to waive any lawsuit, action, or claim for damages against Mason County which may arise out of
Mason County's actions in acceptance, processing and/or issuance of such permits or approvals (hereinafter"permitting
actions'),which damages are attributable to the County's decision to take permitting actions despite the risk that changes
to the County's development regulations might later make the County's permitting actions invalid.
Date (Parcel No. or Legal Description)
Property owner's signature(Notarized)
(or the County may accept the signature of the owner's authorized agent upon proper proof of authorization)
ACKNOWLEDGEMENT CERTIFICATE (INDIVIDUAL) �f
STATE OF v
COUNTY OF
On this day of , in the year ,before me Notary Public,
personally appeared personally known to me to be the person whose name is
subscribed to this instrument,and acknowledged that he/she executed it.
WITNESS my hand and official seal.
-For County use only-
Reviewed by applicant on
(Date)
Notary's signature
Staff Initial:
My Commission Expires: