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Home My WebLink AboutBLD95-0573 Cancelled Addition - BLD Application - 4/24/1995 ' MASON COUNTY Permit No. BUILDING PERMIT APPLICATION 426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 PLEASE PRINT #1 �Vite r %7i3/i;r� /�)V ow i�17 Lu��% �� Phone # ddress G 3% L_'1"a1) `v(/ L�r�/L Z./ Fire District# St L/ii/ . Zip Directions to Job Site 3 *3001ck G�Vk �QAMrC. O'V-4v- n,a-9-r (' a-O-V- �0" So1��,� Ar4n° �p�v�cQ i vt Owner Mailing Address '�,0� �— City St 6-<T Zipl�f 1 Lien/Title Holder Address City St Zip #2 Contractor Name cd" yS GuS ��n�mc{� RirrVV1 ontractor Reg#-'5A-F11JCC 08bOX- Address Expiration Date 2(c / (?6-_ City !�ZA � -S Zip 81 Phone # #3 If septic is located on project site, include records. Connect to Septic?_�_Public Water u ly Well Connect to Sewer System? am of tem {�}� (If residential, proof of potable ater I re d) ' ��+n 9,00 " Z `''I �v CIO - #4 rcel No. Z 13 G - 21 Legal Description I�2 0� n E n E (�t� ,7 z 2-. r �jJ 0��8� #5 Building Square Footage: (existing/proposedT,ZS'* 4-4 1st FI tq G,o / SZ. 2nd FI / 3rd FI / Loft / Basement / Deck' / #bedrooms / #bathrooms / Garage / Carport / (Circle: Attached or Detached?) Other sq. ft. / #6 a of building IJ d. o Describe wo ' �&Wvvetj #7 Type of Job: New Add _Alt Repair Other #8 MOBILE/MANUFACTURED HOME INFORMATION Model Year Make Model 4 1995 Length Width Serial No. # Bedrooms # Bathrooms Type of Heat ES` Purchase Price $ ��TH SERVIC #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 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 <— —> Ito •/( q -� GOLYIvY�� W A..`1 ZS �V APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each) No. Toilets 3 CIRCLE FUEL TYPE: Ga , Electri Bath Basins Heatpump, Other Bath Tubs No. Units Fees Showers 3 Furn BTU Hot Water Htr -� _ Heatpumps Laundry Washer Vent Systems _Sinks 2- Spot Vent Fans l z— Floor Drains No. Boilers/Compressors Laundry Basins _� _ HP Dishwasher No. Air Handling Units _Disposal cfm# Q Q% 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 $3a 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- 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 DATE DATE FOR OFFICIAL USE ONLY:Accepted by: Date: DEPARTMENTAL REVIEW FOR OFFICE USE ONLY Approved Cond. Hold Approval Planning: 6& (Q2-;0191,4yz 1 ✓JI ��/ m Environmental Health: Building Plan Review Occupancy Group: Type of Cons,y Fire Marshal: Other: Special Conditions: FEES _ Building Permit (?/� Plan Check 2� Plumbing Fee 2710 Mechanical Fee D,I Wood/Gas/Pellet Stove Radon Monitor Violation Fee Site Inspection Building State Fee y d Other Other Building Valuation: TOTAL FEE EdMASON COUNTY DEPARTMENT of HEALTH SERVICES Shelton,Washington 98584 (360)427-9670• Belfair:275-4467 ENVIRONMENTAL HEALTH PERSONAL HEALTH WATER QUALITY P.O. BOX 1666 303 N. FOURTH P.O. BOX 1666 January 12 , 1999 Donald Wood 531 E Cranberry Creek Rd Shelton, WA 98584 RE: B1d95-0573 To Whom it May Concern, The above reference permit has been on hold in Environmental Health for at least six months. You must respond to this letter either in writing or by compliance within the next fifteen working days. If you do not respond we will send out an inspector to check if the project has been completed without a permit, a double permit fee will be assessed. If no work has commenced the permit will be canceled and plan check fee of 70 . 00 dollars will be due. If you have any questions please feel free to call me. Thanks, Trish Wagner (360) 427-9670 ext . 287 P.O. Box 1666 Shelton, WA 98584 attachement : copy of original letter to comply s. APPLICANT NAME: Q, DATE: L HE BUILDING PERMIT CHECKLIST SITE ADDRESS � � 9 tIf site address is not listed, customer needs to be given a site address form. FIRE DISTRICTS okm\( Please make sure the fire district is included in the application information. Refer to map located at counr^ DIRECTIONS TO JOB SITE O�6 Needs to be as complete as possible (i.e. major roads, is house on left or right side of road, etc sure to read for clarity (Landmarks, signage, owners name on mailbox, etc.?). }, LIENITITLE HOLDER Who holds the mortgage (Bank or name of private owner holding contract)? CONTRACTOR REGISTRATION # AND EXPIRATION DATE This information needs to be provided. The Building Department may be able to research expiration information if customer does not know it. We must have a signature in 1 of the 2 boxes, either the applicant or the contractor. SEPTIC RECORDS A B WATER COMMUNITY PRIVATE SEPTIC EXISTING DESIGN APP. DEV REMODEL NEW STATUS v�- � t PARCEL # Parcel # must be included or researched through Gateway. ` BUILDING SQUARE FOOTAGE Verify that boxes are filled in. If there is a garage, verify whether it is attached or detached. Include square footage information for mobile homes (you can multiply length X width to determine number). USE OF BUILDING Is it a residence, garage, greenhouse, etc. . .? fl DESCRIBE WORK (i.e. mobile home addition, addition to a house, etc. . .) TYPE OF JOB Verify appropriate boxes are marked. i MOBILE HOME INFORMATION �*f Verify appropriate boxes are marked. If factory order, please put factory order #in mobile home serial #. If unit was assembled prior to June 15, 1976, refer to procedures handout for "Obtaining Installation Permits for Mobiles Assembled Prior to June 15, 1976." SHORELINES If any water is on or adjacent to property within 200 feet, #9 must be complete. Once permit is entered into Tidemark, it will be routed to the Planning Department. If property is not on water, then put "none" or "n/a". 1 e y -� SITE PLAN DRAWING Must have setbacks from all property lines, easement lines and structures. Drainfields septic tank location, outbuildings, etc. . . TOPOGRAPHY DRAWING If property is flat write "flat" on the topography section. If house or structure is near a slope or hill, drawing must reflect this. PLUMBING/MECHANICAL This form must be completed for any structure with plumbing and mechanical excluding mobiles/modulars. OWNER OR CONTRACTOR AFFIDAVIT Owner or contractor must sign affidavit statement and date it. ACCEPTED BY Whoever is accepting permit information must sign your initials and date form on the bottom of page 3 or use date stamp and initial on back of permit. PRINTS Need two sets of prints unless it is a stock plan. For stock plans, we only require one copy. WATER ADEQUACY l For new residences and mobiles. PRIVATE WELLS MUST HAVE WELL LOGS OR CAPACITY TEST AND BACTERIAL TEST. If they are on a public water system, verify the water system is in compliance with State requirements. WSEC & V & IAQ CODE Required for all residential, additions and commercial buildings. Energy Code compliance form needs to be COMPLETED. Verify heat source (no wood or pellet stoves are permitted as primary system). Window schedule must be filled out and reflect what appears on submitted building plans. If applicant has decided to go with the PUD in a Long Term Super Good Cents program, we require a copy of the signed agreement with the utility. ROAD ACCESS PERMIT If you will be accessing your driveway from a County road, contact the Public Works Department in Mason County Building I,427-9670 extension 450. Access from State Highways requires Department of Transportation approval. Contact office (206)895-4753 (Port Orchard). * ACCEPTED BY: 1`--J •' DO NOT ACCEPT PERMIT APPLICATION WITHOUT PRINTS AND REQUIRED DETAILED INFORMATION (SETBACKS, ADDRESSES, PARCEL # AND WATER). checklst.blg 9/20/9 3 2