HomeMy WebLinkAboutBLD N/A Change of Name - BLD Application Permit No.
MASON COUNTY
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628
PLEASE PRINT
#1 ,Owner 1ti K� l� l�y Phone# �' <
• Site Addre s -3:1 /L-r Fire District#
City +� r'.G�,d) St Zip �S
Directions to Job Site
Owner Mailing Address AS
City St Zip
Lien/Title Holder
Address
Clty St Zip
#2 — Contractor Name Contractor Reg #
Address 3'R 1 /'t e" ,' Expiration Date
r
- City 14 St Zip Phone#
#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)
#4 Parcel No. - -
Legal Description
#5 Building Square Footage: (existing/proposed)
1st FI / 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms / #bathrooms /
Garage / Carport / (Circle:Attached or Detached?)
Other sq.ft. /
#6 UseofbuiIdin(_eA1UMg a Describe work
#7 Type of Job: New Add Alt Repair Other
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year Make Model
Length Width Serial No.
#Bedrooms #Bathrooms 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 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
Plumbing Fixtures ( 3 eachl 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 _ 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 DO E WILL BE IN AND ALL WORK DONE WILL BE IN CONFORMANCE
CONFORMANCE THEREWITH. NO CHAN ES SHALL BE THEREWITH. NO CHANGES SHALL BE MADE WITHOUT
MADE WITHOUT FIRST OBTAINING AP OVAL FROM FIRST OBTAINING APPROVAL FROM THE BUILDING
THE BU EPARTMENT. DEPARTMENT.
X OWNE X BY
DATE _ 2 ``� DATE
FOR OFFICIAL USE ONLY:Accepted by pate:
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