HomeMy WebLinkAboutBLD95-01745 Cancelled Change of Use - BLD Application - 12/21/1995 Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION b
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 er �Q - � ( ""' Phone#
' c Fire District#
(FAddress
— St up Zip
rections to Job Site
rloox CA UJ
Owner Mailing Address
City <�-"IJCC3—\ St u—ft _Zip L
Lien/Title Holder
Address
City St Zip
#2 Contractor Name Contractor Reg#
Address xpiration Date
City St Zip Phone#
#3 If septic is located on project site, include records. F
Connect to Septic? Public Water Supply Well
Connect to Sewer System? Name of System S
(If sidential, proof of potable water is required) y✓�n
a
Parce n
9 P
al Description
l No - - C�I s
Le
#5 Building Square Footage: (existing/posed)
1st FI / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle: Attached or Detached?)
Other sq. ft. / �1 "
� l c�c-
#6 Use of building G Describe work
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year Make Mode
Length Width Seri
# Bedrooms # Bat s Type of H
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 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
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
1
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No._Toilets CIRCLE FUEL TYPE: Gas, Electric,
_Bath Basins Heatpump, Other /
_Bath Tubs No. Units Fees
_Showers Furn BTU
Hot Water Htr _ eatpumps
_Laundry Washer Vent Systems
_Sinks _ Spot Vent Fans
_Floor Drains No. Boilers/Compressors
_Laundry Basins _ HP
_Dishwasher No. Air Handlin_ Units
_Disposal _ cfm#
_Urinals Fire Protection Systems
_Other _ uto. Fire Alarm Sys 50.00
Fixe ire Supp. Sys 50.00
Permit Basic F 15.00 Auto Fire ink Sys 25.00
TOTAL UMBING $ 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 OBTAI APPROVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BUILDING DEPARTM DEPARTMENT.
X OWNER X BY
DATE ti DATE
i
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
Environmental Health: I' LAP -�' c�oe5 wad" i w'di(R } +trit- tA�t �tN. PJ
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
Building Valuation: TOTAL FEE
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences OF
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements Indicate directional b
Septic Systems Name of Fronting Street y
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
�ET�Jf�
le
17/
FOR OFFICIAL USE ONLY:Accepted'by . Date:
EPA-FTMENTAL REVIEW
FOR OFFICIAL USE ONLY
Planning APP COND APP HOLD
Building
Fire Marshal _
Other
Special Conditions Fees
Permit Fee $
Plan C ec
Other
Other
State Building Fee
TOTAL DUE w