HomeMy WebLinkAboutBLD95-00181 Cancelled SFR - BLD Application - 9/9/1995 4al Af- P'W t l pyd c es s -{ (r GAA),'
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Permit No.
MASON COUNTY W OqS-:2)
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 Owner Phone#
Site Address C- 3/ Gdk'l klu1 /ac /-atiL Fire District# S
City , 9 N�) St(AA_zip 9F--'n
Directions to Job Site dtvq a 4)oGl Q
e, to aloe La id ZA oty v ER
Owner Mailing Add ss a 031
City F Zip
Lien/Title Holder d ihnd CO.
Address
Clty S 1 Sty , Zip S
Nor
#2 Contractor Name S FAll' HIA Contra eg# AIEN *45 AI '
Address ,0, E tion Dat / ':�A0 / _
City S 1 A) St Zip Phone 6- 7.6 73
#3 If septic is located on project site, include records.
Connect to Septic?__,y_Public Water ply II_
Connect to Sewer System? N Syste
(If residential, proof of a wat i equ )
#4 Parcel No._fz (1 75-
Legal Description 6 /
#5 Building Square Footage: .s ' proposed)
1st FI / / _2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / -'3 Jrbathrooms /
Garage / Carport SAC/ (Circle:Attached etac
Other ft. /
#6 Use of buildina -Describe work
AAW
r7
#7 Type of Job: New ✓ Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORM
Model Year Make del
Length Width erial No.
#Bedrooms # rooms Type of Heat
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 Oth
i
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
LA TP-AINf�rco
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M
J
YT a o kask
ao' EasEM�,vss
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
,�'�Ilow I3IUe �aN�
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. "),Toilets CIRCLE FUEL TYPE: Gas,giED
_Bath Basins Heatpump, Other
Bath Tubs No. Units Fees
Showers Furn BTU
I Hot Water Htr _ 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
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 $ 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. DEPARTMENT.
X OWNER X BY #1 �
DATE DATE 3z7lqS
FOR OFFICIAL USE ONLY: Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICE USE ONLY
Approved Cond. Hold
Approval
Planning:
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
Building Valuation: TOTAL FEE