HomeMy WebLinkAboutBLD95-01209 Cancelled MH Addition - BLD Application - 8/15/1995 Permit No. �ry�'ow d
MASON COUNTY C\
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 Ow AJ f,, f Phone# 6
Site Address S/ C h Fire District#
City St - Zip
Directions to Job Site °2 '
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Owner Mailing Address 5cL-rTL4, 94
City St Zip
Lien/Title Holder 1 , C
Address
Clty St j.- Zip
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#2 Contractor Name - c2�+- Contractor #
Address Expiration [N to
'City St Zip Phone*
#3 If septic is located on project site, include records. aco
LO
Connect to Septic? Af 0 Public Water Supply Well w. L"
Connect to Sewer System? A� n Name of System C
(If residential, proof of potable water is required) Q
# racerI No.� � - �3 - � _ /00
gal Description Set 1 �'�—\ �'
#5 Building Square Footage: (existing/proposed) i ��
�,
� 1 "7 s Ra 3cv
i 1st FI 76 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached Detached.
Other sq. ft. /
#6 Use of building "Y scribe work
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATIDN `^`I
Model Year 9 72-.Make Model
Length Width Serial No.
#Bedrooms - # Bathrooms Type of Heat
Purchase Price$ /�5`t9-C) r 0-0
#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
Az
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 J
APPLICANT TO DRAW SITE PLAN BELOW
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06
0
APPLICANT T DRAW TOPOGRAPHY PROFILE BELOW C O i
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tJo TPA
1
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas,;Electric)
Bath Basins Heatpump, Other
_Ba Tubs No. Units Fees
rM —Shower f Furn BTU
_Hot Water Ht _ 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
Othe i — Auto. Fire Alarm Sys 50�00��
Fixed Fire Supp. Sys 50.00
Pe it Basic Fee 14.00 — Auto Fire Sprink Sys 25.00
TOTAL PLUMBING $ . Other
Gas Outlets
Wood, Gas, Pellet Stove 11
— 1
i
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 PEPARTMENT. DEPARTMENT.
X OWNER X BY
DATE �� �L� DATE
- --�
FOR OFFICIAL USE ONLY.Accepted by: ': Date:
i
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
II
Planning: �►1{�'�
I
Environmental Health:
f
Building Plan Review .r.?rMC.e /.+/ ,44611701fl ti10,-1,16 ,ee 2ASZO `
Occupancy Group: Type of Const: V"-/V _
Fire Marshal:
Other:
C
I
Special Conditions:
FEES
Building Permit
Plan Check 5Z . Oa
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee D V
Site Inspection
Building State Fee ba
Other
Other
Building Valuation: TOTAL FEE ��
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