HomeMy WebLinkAboutBLD95-01494 Cancelled Mobile Home - BLD Application - 10/5/1995 Permit N .
MASON COUNTY b
BUILDING PERMIT APPLICATION a
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-56 1
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PLEASE PRINT
#1 ner = (y��1 A Phone#6
e Address �o � tZ 420 Fire District#
City „ 141,5 R) St o— Zip
Directions to Job Site L� s��� �f� 17a 8g'1pE'E l
af: 02/ vg
Owner Mailing Address 5k-Y�I1-
City St Zip
Lien/Title Holder D)lll�
Address
Clty St Zip
#2 Contractor Name oo> J Contractor Reg#
Address Expiration Date
City St Zip Phone#
#3 If septic is located on pr 'ect site, include records.
Connect to Septic? Public Water Supply Well
Connect to Sewer System? Name of System
Varce
ntial, proof of potable water is required)
# o. I - -
Legal Description i t Z /� T' 3 G�! Cif#5 Building Square Footage: (existing/proposed)
1 st Fl�6 / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other y� sq.ft. / ram"'' c?
#6 Use of building 1 ` 1 V � Describe work
#7 Type of Job: New Add Alt Repair Other AZPCACi�5
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year t�cQ Make'ate f�-KVodel �d
Length Width f 0 Serial No. K . CS -7
# Bedrooms I #Bathrooms Type of Heat fVcC- K,c C
Purchase Price$ eief
#9 Indicate by circlin the applicable source if any water is on or adjacent to subject property:
River Pond Oee Stream Wetland Lake Marsh Saltwater Seasonal Runoff Other
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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
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APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 eat Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other
Bath Tubs No. Units Fees
howers Furn BTU
_Hot ater Htr Heatpumps
Laundry sher _ 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 15.00 Auto Fire Sprink Sys 25.00
TOTAL PLUMBING $ N Other
Gas Outlets
Wo d, 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 TOTAL MECHANICAL $
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 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 �5«nn _ ��c. ti X BY
DATE id DATE
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Id I
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
L=Buildinguation: TOTAL FEE
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