HomeMy WebLinkAboutBLD95-01657 Cancelled SFR - BLD Application - 11/17/1995 Permit No.
MASON COUNTY Jvk �I
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 wner QM',) /` Phone#
Site Addre s 6� 1 c Fire District#
City 5&1 A, St ly Zip 7iP
Directions to Jo ite ,Qe e,- Cie 1er6 ylZ
t, VA) S D Zi` -Lc%.J /V tW-c 9 4l8c)
Owner Mailing Address fP 6
City �Jr!'�1b?����' St AAA- Zip
Lien/Title Holder
Address
Clty St Zip
#2 Contractor Name_ IWObt/ r' 6AA4�7ZyA--- Contractor Reg# OV ayael
Address ,�4r7 �� �LJ�J Expiration Date Z9;� / v? 5 l V&
City st l✓/4' Zip`7�N 7 Phone#.,2et N' 7"74141
#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)
#b� arcel No.�- .t�
Legal Description '4 c'�'!� "";i J`f ��' �j 3 `1
#5 Building Square Footage: (existing/proposed)
1 st FI Z06 67 / 2nd FI / 3rd FI / Loft /
Basement / Deck / # bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other sq. ft. /
#6 Use of building Describe work
#7 Type of Job: New Add Alt Repair er
#8 MOBILE/MAN JJFgCTURED HOME INFORMATION
Model Year 1-'2 Make�/f— Model N 0 V 1 5 j
Length Width 6A 7 Serial No. 5ei 3�7 L�
# Bedrooms 3 # Bathrooms Type of Heat
Purchase Price$ Z-/ HEALTH SERVICES
#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
� l�
3-3el > V
n�KA
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: Gas, Electric,
ath Basins atpump, Other
�Ba Tubs No. Units Fees
�how�rs r `Furn �5 "� BTU
Hot Wat�,r Htr _ eatpumps
Laundry Washer _ V t Systems
Sinks \\�� — Spo Vent Fan
—Floor Drains No Boil r /C m re ors
_Laundry asins HP
Dishw sher No. Air H n ni
Dis osal cfm# /
rinals No. Fir r i nSystems
Other — Au . Fire Alar'I� Sys 50.00
F' ed Fire Sup\p\Sys 50.00
Permit Basic Fee 15.00 _ Auto Fire Sprink S s 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 DEPARTMENT. DEPARTM T. '}
X OWNER X BY �✓�ZZ ,���
DATE ( DATE /
—---------
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health:
Building Plan Review Y AY
Occupancy Group: Type of Const:
Fire Marshal:
Other:
Special Conditions: FEES
Building Permit 100. n 0
Plan Check
Plumbing Fee
Mechanical Fee
Wood/Gas/Pellet Stove
Radon Monitor
Violation Fee
Site Inspection
Building State Fee
Other
Other
Building Valuation: TOTAL FEE