HomeMy WebLinkAboutBLD95-0961 Cancelled Mobile Home - BLD Application - 7/10/1995 Permit No. '
MASON COUNTY -&Iclq 69to 1
BUILDING PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 427-9670/1-800-562-5628 Oq
PLEASE PRINT �
#1 wnerf -�'U_1 /(/ Phone#
ddress iV / �/ T/fyr� -�U�C',� ,/T Fire District#
ity TA' St _Zip 9P
Directions to Job Site 6�A VF- -' L 1Z /J 2 - "S j T/g � �P 5'/GX/ e-1-,E'eET
DN7"0 7l9h'UfTT�L }ems S/I�/Tff �/� �4 fAx /ate
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Owner Mailing Address Pa &DX 2=2-7
city PW,1 oRr 4�5"l StAw Zip gg 3
Lien/Title Holder bvl- [nr/Q/ Fic Vy
Address C O'L _
City K_ iC/`V,� �,U, ��'/� St Zip
#2 Contractor Name //�/��TS^ O LJ�J,� 0QX1e,&
2!f/ S Contractor Reg#a91557Se/O oQr-
Address P D ,Y5DX 2,�7 Expiration Dated/ 7 96
City PDT D ,��4b St�Zip Phone#
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#3 If septic is located on project site, include records. v
Connect to Septic? �blic Water Supply Well
Connect to Sewer System? Name of System
(If residential, proof of potable water is required)
#4 No.2z 0 - Q- O �(,�l
Description , L << 1/0 toa—c / Z L O7 2'
#5 Building Square Footage: (existing/proposed)
1st FIIITIE 2nd FI / 3rd FI / Loft /
Basement / Deck / #bedrooms 3 / #bathrooms2-r/
Garage / Carport / (Circle:Attached or Detached?)
Other sq. ft. /
#6 Use of building /Q,E 2e ,E Describe work .�
#7 Type of Job: New— --Add Alt Repair
#8 MOBILE/MANUFACTURED HOME INFORMATION
Model Year��MakefLff�odel4fl'-5, J U L 0 7 IM
Length �� Width_Serial No.
#Bedrooms # Bathrooms _Type of Heath/ -4: /g �'HEALTH LTH SERVICES
Purchase Price$��Dd
#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 Indicate Directional by (N, S, E, W)
Name of Flanking Street
Name of Fronting Street in relation to plot plan
APPLICANT TO DRAW SITE PLAN BELOW
APPLICANT TO DRAW TOPOGRAPHY PROFILE BELOW
G�d�G�
Plumbing Fixtures ($3 each) Fee Mechanical Fixtures ($6 each)
No. Toilets CIRCLE FUEL TYPE: /Electft,
_Bath Basins Heatpump, Other
Bath Tubs No. Units
Showers Furn
_Hot Water Htr _ Heatpumps
Laundry Was er Vent Systems
_Sinks _ Spot Vent Fan
Floor Dr ins No. B it r /Com r
Laun ry Basins _ HP
Di washer No. Air Hand14 Units
isposal cfm#
Urinals No. Fire P tion 'Systems
Other _ Aut . Fire Alarm Sys 50�00
Fi ed Fire Supp. Sys 50.00
Permit Basic Fee 15.00 uto 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 ermit Basic Fee 15.00
WORK IS SUSPENDED OR ABANDONED FOR A PERIOD TOTAL MECHANICAL $
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 DEPARTMENT. DEPARTMENT.
X OWNER X BY�U
DATE DATE
FOR OFFICIAL USE ONLY: Accepted by: � ?ram,-,�' Date: l.v
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 Ire
Other
Building Valuation: TOTAL FEE